Vol 14, No 2 (2022)

Background. Chronic kidney disease (CKD) is a global public health problem worldwide, associated with an increased risk of cardiovascular and all-cause mortality. objective. identification of the regional features of the causes and rate of progression of ckd in the northern territory. material and methods. the data of the registry of 484 patients of the nephrology department of the Komi republican clinical hospital for 2015-2018 were used; there were 231 (47.7%) men and 253 (52.3%) women. The mean age was 58.8±15.8 years. results. the number of patients with 1 visit - 314, with 2 or more visits - 170 patients. the mean glomerular filtration rate (GFR) was 30.1±19.3 ml/min/1.73 m2. distribution by ckd stages: stage 1 ckd - 1.2%, 2 - 5.6%, 3a - 13.6%, 3b - 12.4%, 4 - 26.4% , 5 - 26.6%. the main causes of ckd: tubulointerstitial nephritis (21.5%), diabetic nephropathy (16.7%), chronic glomerulonephritis (15.7%), hypertensive nephropathy (12.0%), the diagnosis is not defined (12.8%). the average decrease in gfr was 3.99±2.7 ml/min/1.73 m2 during the year of follow-up. in patients with stage 2 ckd, gfr increased by 8.4 ml/ min/1.73 m2 per year, with stage 3 ckd - a decrease by 0.13 ml/min/1.73 m2 per year, with stage 4 - decrease by 5.17, with stage 5 - decrease by 6.8 ml/min/1.73 m2 per year (p=0.034). a direct association of the rate of impairment of renal function with the level phosphate, urea, potassium, proteinuria, esr levels, and an inverse association with the o hemoglobin, gfr levels was revealed. the most frequently prescribed drugs for the treatment of patients were angiotensin-converting enzyme inhibitors (32.4%), calcium channel blockers (47.5%), statins (36.4%), ß-BLOCKERS (35.1%), diuretics (24, 6%), antiplatelet agents (39.9%). Conclusion. Maintenance of a ckd registry allows to identify regional features of ckd and assess the rate of progression of ckd.

Objective. analysis of the spectrum of genetic mutations in patients with atypical hemolytic uremic syndrome (ahus). material and methods. a retrospective study based on the results of a genetic study of 44 patients with ahus, who were followed-up at the Scientific and Practical center for nephrology and Pathology of a transplanted Kidney, City Clinical hospital № 52, from 2014 to 2021. results. mutations in the complement system were found in 68% of patients with ahus. mutations in the cfhri and cfhr3 genes were the most common among ahus-specific mutations in 13 (30%) patients. less common were mutations in the c3 genes - 11 (26%) patients, cfh - 8 (19%) patients, cd46 - 2 (5%) patients. genetic mutations characteristic of ahus (cfhri, cfhr3, cfh, cfi, c3, cd46, thbd) were found in 5 out of 7 patients with obstetric ahus. among 11 patients with ahus in their own kidneys without renal replacement therapy, 6 had pathogenic mutations, which in most cases (4 patients) were represented by cfhri, cfhr3 mutations. in the group of patients with ahus and esrd, pathogenic mutations were found in 8 out of 10 patients, in the group of ahus and cadaveric kidney allotransplantation - in 11 out of 16 patients. in both groups, mutations in c3, cfh and cfhr1, cfhr3 were detected more often, and heart damage prevailed among target organ damage. Conclusion. The data obtained provide information on the genetic causes of the disease and genotype-phenotype correlations that can predict disease progression, response to therapy, and risk of relapse after transplantation. This allows for an individual approach to patient management and treatment based on expert interpretation of genetic profiles, which requires genetic screening in each patient.

Objective. evaluation of the frequency and severity of renal dysfunction in patients with pulmonary embolism (PE) and its impact on the outcome of the disease. material and methods. a retrospective analysis of 109 case histories of patients (men - 45%, women - 55%) who were diagnosed with pulmonary embolism during hospitalization was carried out. The median age of patients was 67 (58; 75) years, 14 (12.8%) patients died in the hospital. results. the proportion of pe patients with kidney dysfunction (egfr<60 ml/min/1.73 m2) was 63.3%. acute kidney injury (AKI) was diagnosed by the value of serum creatinine (scr) in 59.6% of patients with pe, incl. according to the initial scr level (n=54) and scr level in dynamics (n=11). the presence of aki in patients with pe was associated with the severity of respiratory failure, coagulation profile parameters, and parameters of right ventricular dysfunction. a prognostic model was obtained, which consisted of 3 indicators (PESI index score, blood sodium level less than 135 mmol/l, and the initial scr), which made it possible to assess the probability of a lethal outcome in patients with pe. Conclusion. Thus, in the clinical practice of a doctor, when assessing the risk of developing adverse outcomes for patients with pe, it is advisable to take into account the renal function. Patients with aki should be given special attention because of its negative predictive value for in-hospital mortality in pe.

Objective. evaluation of the molecular mechanisms that modulate the rapid elimination of small (<6 mm) stones in the middle third of the ureter. Material and methods. The prospective study included 2і patients with rapid (within 24-72 hours) elimination of stones from the middle third of the ureter against the background of standard lithokinetic therapy. Analysis of the functional activity of receptors that modulate ureteral motility was performed on a platelet suspension in vitro. the following agonists were used: atp, adp, adenosine, epinephrine, angiotensin-2 (Sigma-Aldrich Chemie Gmbh, Germany). platelet aggregation was assessed by the turbidimetric method on a ChronoLog analyzer (usa). results. During the elimination of stones in the first 24 hours of lithokinetic therapy, hyperreactivity of the α2-adrenergic, angiotensin ati, purine P2Y and P2X1 receptors was revealed. this fact confirms the possibility of enhancing the contractile activity of the ureter through the sympathetic-adrenal (sas) and renin-angiotensin systems (ras), as well as the local myogenic mechanism associated with an increase in the extracellular adp level. delayed for 48-72 hour elimination of stones was characterized by modulation of ureteral motility through the α2-adrenoreceptor due to activation of the cas and the atp-induced purine P2X1 receptor. the revealed P2X1 receptor hyperreactivity may be associated with the need to increase the force of contraction of the smooth muscle tissue of the ureter in conditions of limited ras activity and persistent urinary tract ischemia. a necessary condition for the elimination of small stones was the maintenance of the basal level of relaxation of the ureteral muscularis which was achieved by maintaining the adenosine A2A receptor normoreactivity. Conclusion. The variability in the timing of rapid elimination of small stones during lithokinetic therapy is determined by the individual characteristics of the formation and regulation of compensatory mechanisms in the process of nephrolithiasis, the purpose of which is to optimize the processes of contraction and relaxation of the ureteral muscularis.

The aim of the study was to evaluate the data of thromboelastography - indicators of coagulation hemostasis in urological patients against the background of acute renal injury. a detailed assessment of hemostatic parameters makes it possible to adjust therapy in intensive care units and reduce the mortality rate. material and methods. we examined 47 patients who had a serious condition and were treated in the intensive care unit of the GBUZ RM “Republican Clinical Hospital named after S. V. Katkov “, Saransk. Pain was investigated in 2 groups of patients: group 1 was diagnosed with Acute purulent pyelonephritis of a solitary kidney and anuria due to blockage of the ureter; group 2 had a diagnosis of Acute purulent pyelonephritis and infectious toxic shock. On the first day of observation, all patients underwent urine and blood analysis, thermometry, electrocardiography, the concentration of biochemical parameters in the venous blood was determined, the glomerular filtration rate, blood gas composition, and acid-base state were calculated. the patients underwent an ultrasound examination of the kidneys, urinary bladder, liver and gallbladder, pancreas, spleen and, if necessary, underwent survey, excretory, retrograde urography, computed tomography of the abdominal and retroperitoneal organs. Coagulation hemostasis was studied using the apparatus Thromboelastograph teg 5000 thrombelastograph (USA). we determined the main parameters of the coagulation, anticoagulation and fibrinolytic systems. The analysis of hemostasis components included: “LY 30,%” - the percentage of clot dissolution at 30 minutes from the start of the study; “Cl 30,%” is a derived coagulation index (in percent) of several parameters, reflecting the coagulation potential of the patient’s blood as a whole; “R, min” - a time indicator (in minutes), reflecting the duration of the formation of the first fibrin fibers; “A-angle, °” - the angle (in degrees), demonstrating the deviation of the beam from the ox axis with the point of clot formation, characterizes the dynamics of fibrin formation and the level of fibrinogen; “ma, mm” is an indicator of the maximum amplitude, which is recorded before dissolution of the clot during fibrinolysis, reflecting the functional ability of platelets, the amount and quality of fibrinogen. statistical processing of the obtained results was performed using the spss statistica 16.0 program, the results were formatted in Microsoft excel 2003 (Microsoft Corporation, usa) and Microsoft Word 2003 (Microsoft Corporation, usa). results. the results of the analyzes were evaluated separately and in combination with other analyzes. significant changes were revealed in the 1st group of patients. the severity of the patients’ condition was aggravated by long-term difficult-TO-CORRECT gross hematuria after unblocking of the urinary tract, which was based on secondary fibrinolysis in 5 (10.6%) patients. In group 2, versatile changes were found, so in 16 (34%) cases, hypocoagulable changes due to primary and secondary fibrinolysis, as well as a low concentration of platelets. Hypercoagulable changes in this group were observed in 18 (38.3%) patients, of which 6 (12.7%) cases did not reveal any changes in the hemostatic system. Discussion. Acute renal injury is a consequence of an underlying urological disorder. Significant functional and morphological changes in the kidneys are complicated by disorders in the hemostasis system. detection and early correction of a variety of coagulation changes allows minimizing the severity of pathological disorders. conclusion. the use of a thromboelastograph in the assessment of hemostatic parameters (ly 30, cl 30, r, α-ANGLE, ma) allows increasing the accuracy and information content, determining the prognosis and stating the severity of coagulation changes in patients. This is especially important in patients with an extremely serious condition caused by urological pathology, where the prognosis and mortality rate are explained not only by general changes, but also by damage to the renal tissue caused by urological pathology. a detailed analysis of the obtained thromboelastographic data allows for early correction of the revealed changes.

Immunosuppressive therapy after solid organ transplantation significantly increases the risk of developing cancer compared with the general population. we present our own observation of a severe course of metastatic squamous cell skin cancer in a patient with satisfactory graft function io years after cadaveric kidney transplantation, who standard 3-component immunosuppression. despite surgical treatment and a course of radiation, the disease was accompanied by rapid progression and death. Long-term immunosuppressive therapy after kidney transplantation significantly increases the likelihood of developing malignant skin tumors. however, the risk increases significantly over time. therefore, dermatological examinations should be included in the management protocol for renal transplant recipients in order to detect the disease earlier, with particular attention to patients with more than ten years of immunosuppression. if squamous cell skin cancer is confirmed, continued immunosuppressive therapy is associated with a high risk of progression and fatal outcome of the disease.

В Санкт-Петербурге 24.05.2022 состоялся экспертный совет «Терапия минеральных и костных нарушений при хронической болезни почек (хбп). Севеламера карбонат: от контроля гиперфосфатемии к плейотропным эффектам» под председательством профессоров Г.В. Волгиной, Е.М. Шилова и Е.В. Шутова, при поддержке компании «Сотекс». в мероприятии приняли участие главные внештатные нефрологи 8 регионов РФ, представители профессорско-преподавательского состава кафедр нефрологии ведущих учреждений постдипломного медицинского образования. Мероприятие было посвящено проблеме терапии одного из основных осложнений уремии - нарушению минерального и костного метаболизма (МКН-ХБП). Учитывая патогенетическое значение гиперфосфатемии в инициации гормональных и обменных сдвигов, формирующих в дальнейшем клинические проявления МКН-ХБП, в т.ч. внескелетную кальцификацию (прежде всего, сердечно-сосудистой системы), обсуждение было сфокусировано на стратегиях снижения уровня фосфатов. Особое внимание было уделено фосфорсвязывающему препарату севеламера карбонату, который позволяет не только уменьшать фосфатную нагрузку, но и комплексно воздействовать на процессы сосудистой кальцификации за счет подтвержденных плейотропных эффектов.