Clinical nephrology

The latest report of the Specialized Commission for Nephrology of the Ministry of Health of the Russian Federation [1] contains data on the state of the nephrology service of the Russian Federation as of 31.12.2024: Part I “Renal Replacement Therapy”, Part II “General Indicators of the Nephrology Service”. The data cover 98% of the subjects (except for the Chukotka Autonomous Okrug, Zaporizhzhya and Kherson regions), representing 99% of the population of Russia.

Objective. Identification of gender differences in the kidney function in patients with COVID-19.

Material and methods. The study included 504 patients who were treated for the diagnosis of «Novel coronavirus infection caused by the SARS-CoV-2 virus». Patients were divided into two groups by gender: group A – 311 women, the mean age was 63.1±15.3 years, body mass index (BMI) – 28.8±6.1 kg/m2; group B – 193 men, the mean age was 58.3±15.9 years, BMI – 27.8±5.8 kg/m². Blood serum creatinine levels were determined, the glomerular filtration rate (GFR) was calculated.

Results. On admission, 68.8% of women and 53.8% of men had signs of renal dysfunction, since the GFR was reduced; by the 7th day, renal function had not returned to normal in 33.6% of women and 43.1% of men, since the GFR remained reduced.

Conclusion. The course of COVID-19 has gender differences, which must be taken into account in clinical practice.

Objective. Evaluation of the functional state of the kidneys in patients with acute kidney injury (AKI) after COVID-19, one year or more after hospitalization.

Material and methods: The analysis of data from 437 patients who had COVID-19 and were discharged from the hospital in 2021 and 2022 was performed. The creatinine, blood urea, CRP, ferritin, lactate dehydrogenase, interleukin-6 levels during hospitalization and the dynamics of creatinine, blood urea, estimated glomerular filtration rate a year or more after hospitalization and the presence of concomitant somatic diseases were assessed.

Results. At the time of hospitalization, 76 (20.5%) patients had signs of AKI. Patients with AKI were statistically significantly older, they were more likely to have arterial hypertension, coronary artery disease and diabetes mellitus, and they had higher levels of inflammatory markers during hospitalization. One year or more after hospitalization, creatinine and urea levels, as well as the number of patients with stage 3 chronic kidney disease, were higher among patients who had COVID-19 with AKI.

Objective. Analysis of clinical and laboratory predictors of mortality in patients hospitalized for graft pyelonephritis (GP) to improve risk stratification and optimize treatment tactics.

Material and methods. A single-center retrospective study was conducted, which included 501 patients with GP. Demographic, clinical, laboratory and instrumental data, as well as outcomes, were assessed. Logistic regression was used to identify predictors of mortality.

Results. Overall mortality in the study cohort was 5.19% (26 cases). Statistically significant predictors of death were urosepsis (OR=79.97), non-functioning transplant (OR=5.92), presence of lower respiratory tract infection (OR=7.48), blood system pathology (OR=10.27) and cardiovascular diseases (OR=2.52). Based on the risk factors, a prognostic model of the death risk was constructed. The developed model demonstrated high accuracy (AUC=0.96, 95% CI 0.93–0.99), with a sensitivity of 95 ,7% and specificity of 91.2%.

Conclusion. The identified predictors highlight the need for careful monitoring and early intervention in patients hospitalized for graft pyelonephritis, especially in the presence of urosepsis, non-functioning graft and concomitant infectious complications. The prognostic model provides risk stratification for patients, which may improve clinical outcomes.

Background. The most common reason for late diagnosis of urogenital tuberculosis (UGTB) is low alertness of doctors; the second most common reason is the nature of the course of the disease, the absence of pathognomonic signs, the tendency to be mimics of other diseases.

Description of the clinical case. Patient E., 50 years old, complained of pain in the lumbar region and hypogastrium, periodic increases in body temperature to 37.5 ˚С, frequent urination, constant urine output through the vagina. Epidemiological history is burdened. The onset of the disease was at the age of 25, after which the patient repeatedly took courses of antibacterial treatment with little effect. Tuberculosis (TB) was diagnosed only at the age of 50, when kidney function ceased, cicatricial microcystis and vesicovaginal fistula formed.

Conclusion. The given example demonstrates errors in diagnosis. The long-term, recurrent nature of the inflammatory process against the background of repeated courses of antimicrobial therapy, aggravated contact with tuberculosis should have alerted the doctor to UGTB. Progressive decrease in bladder capacity also indicated a specific inflammation. A single negative PCR test for MBT is not a criterion for excluding TB. A decrease in the number of patients with kidney TB does not mean the disappearance of TB in this localization, but only indicates the difficulty of recognizing this disease.

Statin-induced myopathy is an underappreciated clinical problem. According to randomized clinical trials, the drugs are highly safe, however, a number of authors note that intolerance to statins can be observed in every 7–10 patients, and statin-associated muscle syndromes (SAMS) are even more common (up to 29%).

A case of acute kidney injury while taking statins is presented, demonstrating the difficulties of differential diagnosis of kidney damage in comorbid elderly patients. An 83-year-old man was delivered in serious condition from another hospital with a diagnosis of end-stage CKD. Upon admission, an increase in myoglobin to 262144 was noted, CPK total. >80 ULN (upper limit of normal), LDH >8 ULN, AlAt >30 ULN, AST >19 ULN, creatinine – 589 U/l, urea – 32.7 mmol/l, as a result of which the diagnosis was revised in favor of SAMS: rhabdomyolysis with the development of myoglobinuric nephrosis (a variant of tubulointerstitial nephritis), statin-induced liver damage (drug-induced hepatitis). Four risk factors for the development of SAMS were immediately identified: old age, hypothyroidism, impaired renal and liver function, high-dose statin therapy (atorvastatin 80 mg, rosuvastatin 40 mg per day). In the hospital, the patient received complex therapy (including: acute hemodialysis, plasmapheresis, correction of anemia, forced diuresis, correction of hypothyroidism), after which he was discharged in satisfactory condition.

Thus, when prescribing statins, special attention should be paid to comorbid elderly patients who already have kidney disease, thyroid disease and other risk factors for the development of adverse reactions, and, if possible, eliminate them. Then select the dose individually and promptly assess the safety of the therapy.

Thrombotic microangiopathies (TMAs) are a heterogeneous group of diseases with similar clinical and morphological picture, but different pathogenetic mechanisms of development and targeted approaches to treatment. TMA syndrome is characterized by a special type of vascular damage of the microcirculatory bed, which is based on endothelial damage with subsequent thrombus formation, and is manifested by the so-called thrombotic microangiopathic triad, which includes thrombocytopenia, microangiopathic hemolytic anemia and ischemic organ damage. Primary and secondary forms of TMA are distinguished. Primary TMAs include: thrombotic thrombocytopenic purpura (TTP), infection-induced TMA (STEC-HUS, SPA-HUS, virus-associated HUS), atypical hemolytic uremic syndrome (aHUS). Secondary TMAs can be associated with pregnancy, transplantation, medication, malignant arterial hypertension, oncopathology, autoimmune diseases, infections, cobalamin deficiency and account for 80-90% of all TMAs. Primary forms of TMAs are orphan diseases with a prevalence of up to 10 people per 1 million population, are characterized by a severe course and have features of pathogenetic therapy.

Verification of TMA syndrome based on the detection of thrombotic microangiopathic triad is the first stage of diagnosis of diseases of this group, and its confirmation serves as the basis for the initiation of therapy in the form of high-volume plasma exchanges (PE). The second stage of diagnostics involves verification of the etiologic diagnosis and transition to the final treatment protocol. The central place in the differential diagnostics of TMAs is the determination of the activity of metalloproteinase ADAMTS-13 in the blood plasma to exclude TTP, an urgent condition requiring the appointment of a specific treatment protocol, including PT, recombinant ADAMTS-13, immunosuppression, inhibitors of the interaction of von Willebrand factor with platelets. When TTP is excluded, further diagnostic search is based on clinical suspicion with subsequent performance of appropriate laboratory tests to verify STEC-HUS, secondary TMAs.

Atypical HUS, as a diagnosis of exclusion, refers to a severe form of TMA, which also requires a special therapeutic approach in the form of complement blocking therapy, which significantly improves survival and renal outcomes. In this case, atypical HUS should be suspected in all patients with TMA syndrome in the absence of an effect on the etiotropic, symptomatic treatment of any TMA-associated conditions.

Due to the increasing prevalence of obesity and diabetes worldwide, the overall incidence and prevalence of non-alcoholic fatty liver disease (NAFLD) is expected to increase. Risk factors for NAFLD are associated with the development of chronic kidney disease (CKD). This article discusses the epidemiology, risk factors, genetics, and specific pathogenetic mechanisms linking NAFLD with CKD: ectopic lipid accumulation, cellular signaling disorders, the relationship between fructose consumption and uric acid accumulation, etc. The possibilities of early diagnosis of these pathological conditions using fluorescence organoscopy are discussed.