Subacute aortic dissection – case report

60-godišnjeg bolesnika s poznatom ljevostranom nefrolitijazom i arterijskom hipertenzijom. Hitna je služba u nekoliko navrata obrađivala zbog boli u lumbalnoj regiji. Tijekom obrade utvrđene su povišene vrijednosti arterijskog tlaka i povišene razine kreatinina u serumu, međutim, bez prikladnog ultrazvučnog prikaza desnog bubrega. Pri obradi u našoj ustanovi ultrazvučno i obojenim doplerom postavljena je sumnja na infarkt desnog bubrega, koja je potvrđena MSCT angiografijom uz popratnu disekciju descendentne aorte. Cilj je ovog članka upozoriti na potrebu proširenih dijagnostičkih pretraga pri pojavi naglo nastale boli u lumbalnoj regiji radi isključivanja potencijalno fatalnih komplikacija i prevencije smrtnog ishoda.A 60-year-old man with previously known left-sided nephrolithiasis and arterial hypertension has been examined several times in an emergency room because of the pain in the lumbar area. During an examination, high blood pressure and increased creatinine levels have been verified, without adequate ultrasound of the right kidney. During an examination in our hospital, kidney ultrasound and color Doppler showed suspected infarction of the right kidney. MSCT angiography showed the infarction of the right kidney and the dissection of the descending aorta. The purpose of this article is to warn about the importance of expanded diagnostic procedures when an acute lumbar pain occurs, in order to exclude potentially fatal complications and to prevent lethal outcome

Smjernice za dijagnosticiranje i liječenje hipertenzije ESH/ESC 2007. - što nam donose novo?

Nove smjernice za dijagnosticiranje i liječenje arterijske hipertenzije ističu važnost ukupnoga kardiovaskularnog rizika u odnosu na arterijski tlak, uvedeni su novi čimbenici u stratifikaciji kardiovaskularnog rizika, novi dijagnostički postupci, kao i postupci za procjenu oštećenja ciljnih organa. Posebna pažnja posvećena je bubrežnoj bolesti čiji se parametri sada preporučuju u rutinskoj primjeni pri procjeni oštećenja ciljnih organa, a kao nova kategorija u stratifi kaciji kardiovaskularnog rizika pojavljuje se metabolički sindrom. Pri liječenju važno je težiti smanjivanju oštećenja ciljnih organa i prevenciji nastanka visokorizičnih stanja, a ne samo prevenciji kardiovaskularnih incidenata. S tim ciljem preporučuje se provođenje nefarmakoloških mjera u svih bolesnika. Ističe se ravnopravnost svih 5 skupina antihipertenziva u započinjanju liječenja, ali i dijabetogeni učinak β-blokatora i diuretika. Naglašena je nevažnost odabira prvog lijeka s obzirom na to da većina hipertoničara treba kombinirano liječenje uz poštovanje prednosti pojedinih lijekova u određenim kliničkim stanjima. Smjernice su zadržale svoj savjetodavni karakter i težnju k individualnom pristupu s ciljem što bolje primjene u svakodnevnoj praksi

Usporedba ostijalnog i trunkalnog suženja bubrežne arterije: prediktor proširenosti ateroskleroze velikih arterija i veće smrtnosti

The aim of this study was to determine arterial stiffness and the effect of stenting in patients with renal artery stenosis. We hypothesized that ostial renal artery stenosis is not only a marker of more pronounced atherosclerosis of large arteries, but is also a predictor of higher cardiovascular mortality. We enrolled 33 patients with renal artery stenosis refractory to pharmacological treatment and divided them according to the renal artery stenosis location, ostial and truncal (23 vs. 10 patients). We analyzed patient survival at five-year follow up. After the intervention and at sixmonth follow up, there was a significant decrease in blood pressure values, as well as in pulse wave velocity (PWV) and augmentation index. PWV was significantly lower in patients with truncal renal artery stenosis and these patients were significantly younger. Twelve patients with ostial and one patient with truncal renal artery stenosis (52% vs. 10%, p<0.001) died from cardiovascular events. Our study is the first to confirm the predictive role of PWV and arterial stiffness in patients with renal artery stenosis, especially ostial one, and to emphasize its ability of detecting future higher incidence of cardiovascular events.Cilj ovog istraživanja bio je utvrditi krutost arterija i učinak stentiranja u bolesnika sa suženjem bubrežne arterije. Hipoteza je bila da ostijalno suženje bubrežne arterije nije samo pokazatelj izraženije ateroskleroze velikih arterija, nego je i prediktor veće kardiovaskularne smrtnosti. U istraživanje smo uključili 33 bolesnika sa suženjem bubrežne arterije koji su bili refraktorni na farmakološko liječenje i podijelili ih prema položaju suženja bubrežne arterije, ostijalnom i trunkalnom (23 naspram 10 bolesnika). Analizirali smo preživljenje bolesnika nakon petogodišnjeg praćenja. Neposredno nakon intervencije i šest mjeseci nakon intervencije došlo je do značajnog smanjenja vrijednosti krvnog tlaka, kao i brzine pulsnog vala (PWV) i indeksa augmentacije. Brzina pulsnog vala (pulse wave velocity, PWV) je bila značajno niža u bolesnika s trunkalnim suženjem arterije i ti su bolesnici bili značajno mlađi. Dvanaest bolesnika s ostijalnom i jedan bolesnik s trunkalnim suženjem bubrežne arterije (52% naspram 10%, p<0,001) umrlo je od kardiovaskularnih događaja. Naša studija je prva koja potvrđuje prediktivnu ulogu PWV i arterijske krutosti u bolesnika sa suženjem bubrežne arterije, osobito ostijalnim, te naglašava njezinu sposobnost otkrivanja buduće veće incidencije kardiovaskularnih događaja

Reaktivna i klonska trombocitoza: citokini i reaktanti akutne faze

Platelets are acute phase reactants that increase in response to various stimuli, including systemic infections, inflammatory conditions, bleeding, and tumors. This is called reactive or secondary thrombocytosis, which is a benign form of thrombocytosis. Clonal thrombocytosis is an unregulated abnormality of platelet production due to clonal expansion of bone marrow progenitor cells. Secondary thrombocytosis may be due to the overproduction of proinflammatory cytokines such as interleukin-1 (IL-1), IL-6, and IL-11, which occurs in chronic inflammatory, infectious and malignant states. The presence of elevated IL-1, IL-6, C-reactive protein and granulocyte-macrophage colony-stimulating factor in individuals with this condition suggests that these cytokines may be involved in reactive thrombocytosis.Trombociti su reaktanti akutne faze i njihov se broj povećava kao odgovor na različite podražaje, uključujući sistemske infekcije, upalna stanja, krvarenja i tumore. To se naziva reaktivnom ili sekundarnom trombocitozom, što je benigni oblik trombocitoze. Esencijalna trombocitoza je nenormalna proizvodnja trombocita uzrokovana klonskom ekspanzijom progenitorske stanice koštane srži. Sekundarna trombocitoza može biti uzrokovana prekomjernom proizvodnjom proupalnih citokina, kao što su interleukin 1 (IL-1), IL-6, IL-11, koji se javljaju u kroničnim upalnim, infektivnim i malignim stanjima. Prisutnost povišenih vrijednosti IL-1, IL-6, C-reaktivnog proteina i granulocitno-makrofagnog faktora stimulacije rasta u pojedinaca s ovim stanjem ukazuje kako bi ovi citokini mogli biti upleteni u reaktivnu trombocitozu

Sakubitril/valsartan u kliničkoj praksi: pogled nefrologa

In April 2019, the symposium “Controversies in hypertension, cardiovascular protection and nephrology” was held in Zagreb. In dynamic and interesting ways, various subspecialists presented strategies of treating patients with numerous comorbidities, the complexity of the treatment strategy, and the risk of side effects. Guidelines were published, but despite them or even because of them, we have realized that an individual approach to the patient remains crucial to the decision on the treatment. The goal of this article is to describe the controversy over the application of sacubitril/ valsartan in patients with chronic kidney disease.U travnju 2019. godine u Zagrebu je održan Simpozij „Kontroverze u hipertenziji, kardiovaskularnoj protekciji i nefrologiji“. Na dinamičan i zanimljiv način razni supspecijalisti predstavili su strategiju liječenja bolesnika s brojnim komorbiditetima, njezinu kompleksnost te rizik od nuspojava nekritičnih primjena lijekova. Objavljene su smjernice, ali usprkos ili upravo zahvaljujući njima, došlo se do spoznaje da je individualan pristup bolesniku i dalje ključan pri odluci o načinu liječenja. Svrha je ovoga članka prikazati kontroverzu primjene sakubitril/valsartana u bolesnika s kroničnom bubrežnom bolesti

Prognostičko značenje serumske razine BNP na uspjeh endovaskularne intervencije u renovaskularnoj hipertenziji

Optimal therapeutic approach in renovascular hypertension (RVH) is still controversial. Beside debate on whom and when intervention might be beneficial, this study analyzed whether elevated BNP levels before the intervention can be a predictor of a successful outcome on blood pressure and renal function. In everyday clinical practice physicians are still reluctant in prescribing drugs that inhibit renin-angiotensin system after the procedure. This study also analysed safety and possible positive effects of sartans in patients with RVH after procedure. Arterial stiffness is an independent cardiovascular risk factor. Aging, high blood pressure and increased renin-angiotensin system activity contribute to increased arterial stiffness in patients with RVH. A literature search failed to identify any study related to this topic. Therefore, aim of this study was to determine the arterial stiffness in patients with RVH and analyzing whether stenting in addition to multifactorial drug therapy has beneficial effects on markers of stiffness and the clinical course. Thirty seven patients with RVH were enrolled. The inclusion criteria were: serum creatinine 5 mmol/L), pregnancy and nephrotic proteinuria. Office and ambulatory blood pressure (BP), augmentation index (AIx), pulse wave velocity (PWV), central mean BP (MAP) , eGFR and serum potassium were determined before stenting, 48 hours 6 and 36 months after the intervention. Telmisartan 80 mg (on top) was induced in all patients after stent placement. Significant decrease in NT-proBNP( > 30%) had most of the patients 48 hours after stenting. Significant decrease in BP and improvement in kidney function were observed in this cohort of RAH subjects six months after stenting already. Significant decrease in AIx could be explained with improved renal function but also might be due to the treatment with sartans. PWV is not decreased 6 months after stenting, but decreased significantly after 36 months. Results of this study indicate that intervention in RAH, at least six months after the intervention has beneficial effect on BP and kidney function. Treatment with sartans after stenting in patients with RVH is safe and might contribute to overall positive effect. In conclusion, this study is the first to show that arterial stiffness is higher in patients with refractory RVH than in those with essential hypertension. NT-proBNP and markers of arterial stiffness determined before revascularization were not predictors of either BP or kidney function outcome