Patient education in Hungary.

Patient education is a highly context dependent activity. The Hungarian scene is conditioned by three well articulated aspects. First, the well developed and still cherished roots of dissemination of knowledge; second, the traditional sensitivity of ethical issues in health related, including death and dying issues; third, the present fast socio-political changes in this country. The health promoting hospital movement's widespread activities as well as behavioral sciences, mental health and health psychology aspects of patient education are also reviewed. The theoretical as well as skills aspects of communication and systematic attempts to increase the effectiveness of interactions are also presented.

[Paracetamol-induced tubulointerstitial nephritis in a chronic alcoholic patient]. / Paracetamol indukálta akut tubulointerstitialis nephritis krónikus alkoholfogyasztó betegben.

Hepatic and renal toxicity of paracetamol overdosage is well known like the fact that ethanol enhances the toxicity of the drug. Scanty data report on reversible hepatic and renal failure appearing after therapeutic dose of paracetamol in alcohol-abusers. Renal damage might also occur without gross hepatocellular damage in alcoholics. We report the case of a young alcoholic male whose first renal biopsy disclosed mesangiocapillary glomerulonephritis. One month later he took 1.5 g paracetamol to control the fever caused by upper respiratory tract infection. Soon he got hospitalised due to fever, toxicoderma, elevated liver and renal function test. While liver enzymes returned to normal, macroscopic haematuria, nephrotic range proteinuria oliguria, uraemia developed. A repeated renal biopsy revealed severe interstitial inflammation, tubular atrophy, progression of the vascular changes seen in the first biopsy. Haemodialysis was started and he got steroids (1 mg/kg body-weight) besides aggressive antihypertensive medication. He showed considerable recovery of renal function in some weeks. The case points to the possibility that paracetamol--even in therapeutic dosage--might result in hepatic and renal damage in alcoholics. The sudden deterioration in renal function was due to the acute tubulointerstitial nephritis superimposed on mesangiocapillary glomerulonephritis, provoked by paracetamol. Early diagnosis, immediate withdrawal of the toxic drug, steroid treatment might have kidney and life saving effect.

[Thin glomerular membrane nephropathy. Clinico-pathological observations]. / A vékony glomerularis basalmembran nephropathia. Klinikopatológiai megfigyelések.

In two nephrology centres between 1983 and 1993 among 1545 kidney biopsies 34 cases of thin basement membrane nephropathy have been diagnosed. All patients had a varying degree of microscopic dysmorph haematuria, occasional slight proteinuria--except two nephrotic children; and normal blood pressure with one exception. 5 children and 7 adults experienced repeated bouts of macroscopic haematuria mainly after exercise or upper respiratory tract infection, one child after tonsillectomy. All patients had normal renal function and retained it during the follow-up period (mean 61 months, 3 months to 22 years), except a 46 year old patient, who was found to have the joint occurrence of light chain gammopathy and hypertension. Seven patients had positive family history for microscopic haematuria, in four family members of three patients renal biopsy disclosed mesangioproliferative glomerulonephritis with thin GBM segments. As a cut off value for thin basement membrane nephropathy we considered 264 nm. The morphometric analysis of the electron micrographs revealed a mean thickness of 210 nm. No differences in basement membrane thickness were measured regarding gender, age or the presence of macroscopic haematuria. The thin basement membrane is considered to be the pathological basis and predisposing alteration leading to haematuria.

[Nail-patella syndrome: clinico-pathologic characteristics]. / A köröm-patella syndroma: klinikopatológiai jellegzetességek.

The nail-patella syndrome is a hereditary disorder showing an autosomal dominant trait. It is characterized by a series of skeletal disorders and nephropathy. The skeletal defects and the renal involvement might occur separately. The usual clinical presenting syndromes of the nephropathy are asymptomatic proteinuria, microscopic haematuria and sometimes nephrotic syndrome. In a considerable proportion of patients renal failure develops. We summarise the clinico-pathological features of the disease presenting in two children and in a young man. The two children showed heavy microscopic occasionally, macroscopic haematuria, asymptomatic proteinuria and the adult patient had nephrotic syndrome. Nail-patella abnormalities were observed in one child without the involvement of family members. Except for the mother of the other child no urine abnormalities could be demonstrated in the patient's families. The kidney biopsy revealed the characteristic signs of the nail-patella syndrome in different extent: bundles of collagen fibrils in the glomerular basement membrane (GBM). Segmental and thinning of the GBM also occurred in the two children. This defect predisposes to the clinically dominant micro- and macroscopic haematuria. These children's reual function remained stable during the follow-up period of 4-7 years. In the GBM of the third patient small subepithelial electron dense deposits-corresponding to stage I. membranous glomerulonephritis- and extensive collagen deposition was found. After two years follow-up persistent nephrotic syndrome and gradual decline in renal function could be observed.

Paracetamol induced acute interstitial nephritis superimposed on mesangiocapillary glomerulonephritis.

We report the case of a young alcoholic male whose first renal biopsy disclosed mesangiocapillary glomerulonephritis. One month later he took 1.5 g paracetamol to control the fever. Soon he got hospitalized due to toxicoderma, elevated liver and renal function tests. While the liver enzymes returned to normal, uremia developed. A repeated renal biopsy revealed severe interstitial inflammation, tubular atrophy. Haemodialysis was started and he got steroids (1 mg/kg body weight). He showed considerable recovery of renal function in some weeks. The case points to the possibility that paracetamol-even in therapeutic dosage-might result in hepatic and renal damage in alcoholics.

[The thinning of the glomerular basal membrane in IgA glomerulonephritis]. / A glomerularis basalis membrán elvékonyodása IgA glomerulonephritisben.

Ultrastructural changes of the glomerular basement membrane (GBM) in 34 patients with IgA nephritis and their possible correlation with the main clinical symptoms were examined. In 23 patients thinner than normal GBM segments were found with a mean thickness of 116-120 nm (measured by the method of Osawa). Often foot process fusion but neither disruption nor deposition of immune complexes was seen in the affected capillaries. All patients had hematuria, while those with thin GBM segments had more severe hematuria and more episodes of macrohematuria. Other clinical features were unrelated to ultrastructural changes. It is suggested that the thin GBM may be a predisposing factor to hematuria.

[IgA and IgG antibodies to Chlamydia in IgA nephropathy as well as in mesangiocapillary and membranous glomerulonephritis]. / Chlamydia elleni IgA és IgG antitestek IgA nephropathiás, mesangiocapillaris és membranosus glomerulonephritises betegekben.

It might be supposed that, among the antigens causing chronic immune complex glomerulonephritis (IC GN), there are foreign materials, e.g. bacterial antigens penetrating the mucosal barrier. To put this hypothesis to the test, the presence and titres of IgA and IgG antibodies against Chlamydia (C., one of the most frequent bacteria causing mucosal inflammation) have been studied in the sera of 70 patients with IgA nephropathy (IgA NP), of 25 with mesangiocapillary GN (MCGN) and of 27 with membranous GN (MGN) using a single serovar (L2) inclusion immunoperoxidase assay. Significantly more IgA (titres greater than or equal to 8) and IgG (titres greater than or equal to 32) antibodies were found in the sera of IgA NP and MCGN patients than in healthy controls. These results are compatible with the hypothesis that there are some similarities between the clinical and morphological picture of IgA NP and MCGN. Furthermore, it may be assumed that in renal patients with an active C. infection (high IgG titres with IgA seropositivity) C. antigens may play a role in the production of nephropathogenic IC developing in antibody excess.

[Mesangiocapillary glomerulonephritis, type 3]. / A mesangiocapillaris glomerulonephritis 3. típusáról.

Authors describe in 2 cases of type 3 mesangiocapillary glomerulonephritis the typical histological, pathological and clinical features of the disease. It is considered to be an ultrastructural variant of mesangiocapillary glomerulonephritis accompanied by focal subepithelial deposits reminiscent of membraneous glomerulonephritis. As the background of immune-complex deposition the increase of capillary permeability observed often in diabetes mellitus is discussed. On the basis of its more benign course this pattern is thought to be a separate subtype.

Immune complex nephropathies in patients with malignant tumours.

The authors have studied the incidence of changes related to immune complex glomerulonephritis in postmortem kidney specimens from 23 patients with malignant tumours (18 solid tumours and 5 leukaemias), using light microscopy and immunofluorescence. As revealed by light microscopy, 4 kidneys had diffuse, 2 focal mesangial proliferative glomerulonephritis and 1 IgA glomerulonephritis. Granular deposition of immunoglobulin in the mesangium was observed in 5 kidneys, on 3 occasions together with C3. In only 2 patients were, in addition to glomerular damage, clinical symptoms observed. No CEA and alpha FP were found in the diseased kidneys. The results suggest that glomerular damage with no or only occasional clinical symptoms is not rare in patients with malignant tumours.

Antibodies to viruses of the herpes group in glomerulonephritis of membranous, membranoproliferative and IgA types.

Sera of 25 patients with membranous glomerulonephritis (MGN), 16 with membranoproliferative glomerulonephritis (MPGN) and 54 with IgA glomerulonephritis (IgA GN) were studied for complement-binding antibodies to herpes simplex virus (HSV), cytomegalovirus (CMV) and antibodies to various Epstein-Barr virus (EBV) associated antigens, as also for the titres of these antibodies. The sera of 220 normal individuals served as controls, 120 controls being used for each case. Anti-HSV titres of greater than or equal to 1:64 were found to occur in the sera of all three GN groups in a higher proportion than in those of the controls. This was also valid for the complement-binding antibodies to CM, although here the differences were not invariably significant. IgA antibodies reacting with EBV capside antigen (EBVCA) were likewise of statistically increased frequency in IgA GN, as also in MPGN, and in these two groups the geometric mean of the reciprocal value of the IgA antibody titres was also higher than either in the controls or in MGN. The results of the studies carried out within 6 months after onset of renal disease point to an EBV infection, either fresh or having taken place in the recent past, in 20 cases. These data are compatible with a direct or indirect role of EBV in the production and/or persistence of certain types of GN. The high anti-HSV and CMV titres suggest that in a number of patients with renal disease the immune responses to certain types of the HSV group may be abnormal.

Cryoglobulinaemia and cryofibrinogenaemia in IgA nephropathy: a follow-up study.

Sera and plasmas from 50 patients with IgA nephropathy (IgA-NP) have been investigated for the presence of cryoglobulin (CG) and cryofibrinogen (CF), respectively, 2-5 cryoprotein determinations being made for each patient. CG was transiently found in 20 of 50 patients (40%), but in none of 20 healthy blood donors, whereas CF was found in 37 of 50 patients (74%) and in 4 of 20 healthy blood donors. The cryoprecipitates were of single and mixed component types. All but 2 of the patients with CF had haematuria. Nearly all of them had histories of long exposure to the cold as manual workers at the onset or recognition of their disease. There was no clinical remission during a 2-to-5-year follow-up if cryoproteinaemia persisted. A certain correlation was detected between the composition of the CP and the renal immunohistological findings. It is suggested that renal deposition of circulating CF or local formation of CF might be responsible for the tubulo-interstitial fibrocellular changes, which are of prognostic importance.

Differentiation of glomerular and non-glomerular haematurias on basis of the morphology of urinary red blood cells.

Haematurias present serious problems in differential diagnostics. Although no clear-cut instructions exist, patients with haematuria are usually directed to urological surgeries or inpatient departments. Here they are routinely checked by a number of invasive techniques (cystoscopy, i. v. urography, aortography etc.) before the urological nature of haematuria can be ruled out. The suspicion of a glomerular disease being in the background of haematuria emerges only if it is accompanied by a marked proteinuria. Our department deals with kidney diseases since decades. The routine light microscopic examination of haematuric urinary samples called attention to the fine differences between erythrocyte morphology in glomerular and other haematurias. The present paper is an account of morphological studies of red blood cells carried out in haematuric urinary samples of 120 histologically verified glomerulonephritis and 80 other cases.

The role of the tubulointerstitial changes in the prognosis of IgA glomerulonephritis.

The authors investigated the tubulointerstitial changes (atrophic tubuli, interstitial fibrosis and round-cell infiltration) by two methods in renal biopsies from 56 patients with IgA glomerulonephritis. A statistically significant correlation was found to exist between the tubulointerstitial changes and serum creatinine level at the time of renal biopsy. A statistical significant correlation was also established between serum creatinine at the end of a period of 5 years of follow-up and tubulointerstitial changes. Their results suggest that severe tubulointerstitial lesions in IgA glomerulonephritis carry a poor prognosis.