IntroductIon Nitric oxide (NO), released from the endothelial cells, is a potent vasodilating agent with antiatherogenic properties. 1 Several protective properties of NO in the vasculature are linked, among others, to the inhibition of platelet adhesion and aggregation, ability to lower the expression of endothelial surface adhesion molecules, lowering adhesion and infiltration of inflammatory cells into the endothelium, and reducing oxidative stress. NO may also contribute to regeneration of damaged endothelium, since it can mobilize the release of endothelial progenitor

Cardiovascular (CV) disease, its associated risk factors and continued progression run in parallel with renal deterioration (cardio-renal syndrome). Most guidelines promote early treatment, including the use of ACE inhibitors to control CV risk in patients with chronic renal failure. The renoprotective effects of the ACE inhibitor, benazepril, independent of blood pressure control, have been demonstrated, as monotherapy or in combination with amlodipine or hydrochlorothiazide, in large clinical trials: Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) and Gauging Albuminuria Reduction with Lotrel in Diabetic Patients with Hypertension (GUARD) in patients with mild-to-severe chronic kidney disease. In the ACCOMPLISH trial, CV outcomes and renoprotective effects were greater in patients receiving benazepril in combination with amlodipine; the GUARD trial demonstrated that combined benazepril/hydrochlorothiazide was more effective than amlodipine combined with benazepril in reducing baseline urinary albumin:creatinine ratio and normalizing urinary albumin:creatinine ratio in patients with baseline microalbuminuria, although this effect was accompanied with a greater decrease in glomerular filtration rate than with benazepril/amlodipine. While this is not a study in patients with overt renal disease (patients had severe CV diseases), the ACCOMPLISH trial is the first large study to date to show the added benefit of combining ACE inhibitors and calcium-channel blockers in renal protection. Future large, well-controlled trials, designed to evaluate hard renal outcomes, are required to identify which patients will benefit most from particular combination treatment strategies in renoprotection.

IntroductIon Chronic kidney disease (CKD) has relatively asymptomatic course, but even at its onset, it worsens the prognosis of patients, mainly because of the increased risk of cardiovascular diseases. Several population-based screening programs as well as initiatives focused on certain risk groups were undertaken to better diagnose early stages of CKD. It appears that an emergency department (ED) of a hospital may be the right place to screen for early CKD. objEctIvEs The aim of the study was to assess the accuracy of ED practices in the detection of CKD. PAtIEnts And mEthods The study involved 176 subjects who presented at the ED over 1 month and were subsequently admitted to one of the wards at the general hospital. Blood pressure on admission was recorded in 61% of the patients; serum creatinine and estimated glomerular filtration rate (eGFR) were measured in 50% of the subjects, urea in 42.2%, potassium in 87.5%, and glucose in 82%. Patients with previously diagnosed CKD were excluded from the study.

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reference limit, 125 pg/ml) and eosinophilia reached 64.5%. Cardiac MRI (considered an excellent tool to diagnose heart involvement in EGPA) 2 revealed lesions corresponding with endomyocardial inflammatory infiltration and thrombosis in both ventricles ( Figure 1AB). Perinuclear antineutrophil cytoplasmic antibody (pANCA) titer was positive (1:80). Based on the clinical picture and test results, we suspected EGPA. The patient was treated with methylprednisolone (3 intravenous pulses of 0.5 g followed by 32 mg/d orally) and with subcutaneous enoxaparin followed by warfarin. His general status improved within a few days, and pANCA titer decreased to 1:10 after 3 months. Methylprednisolone was tapered to a maintenance dose of 4 mg/d. Echocardiography was performed regularly during follow-up to monitor regression of cardiac lesions. Follow-up cardiac MRI was repeated at 3 months and revealed complete resolution of infiltrative and thrombotic lesions ( Figure 1CD). Currently, the patient is in an excellent general condition and is awaiting a kidney transplant.Patients with ESRD caused by small vessel vasculitis are carefully monitored because life-threatening nonrenal flares (including cardiac manifestations) are common (especially in granulomatosis with polyangiitis).3,4 However, in our patient, the early (prodromal) symptoms of the disease during a predialysis period were overlooked (probably because another cause of ESRD was established, and no other ACR criteria were fulfilled at the onset of the disease). The patient presented with a fulminant, life-threatening flare while already on hemodialysis.Eosinophilic granulomatosis with polyangiitis (EGPA, formerly known as Churg-Strauss syndrome) is a rare autoimmune vasculitis with an incidence of less than 3 cases per million. Heart involvement is observed in 27% to 47% of the patients and remains the main predictor of poor long-term prognosis and premature mortality, although it is not included in the diagnostic criteria of EGPA developed by the American College of Rheumatology (ACR). 1We present the results of cardiac magnetic resonance imaging (MRI) in a patient on chronic hemodialysis (end-stage renal disease [ESRD] secondary to reflux nephropathy followed by nephrectomy) who developed progressive heart failure due to EGPA.A 34-year old man was referred to a renal clinic with advanced chronic kidney disease (estimated glomerular filtration rate, 26 ml/min/1.73 m 2 ). He was diagnosed with vesicoureteral reflux soon after birth. Because of complications, he underwent right-side nephrectomy in early childhood and received conservative treatment for the next 3 years until ESRD developed. Owing to nonspecific symptoms from the upper respiratory tract and occasional eosinophilia (7%-24%), he was consulted by a pulmonologist and diagnosed with asthma. He received fluticasone/salmeterol and levocetirizine. At the age of 37, soon after hemodialysis was started, he was admitted to the Department of Nephrology with fever and acute dyspnea. Echocardiography revealed large ...