Clinical nephrology

The next report of the Specialized Commission for Nephrology of the Ministry of Health of Russia [1], which is published in two parts (Part I. “Renal Replacement Therapy”, Part II. “General Indica-tors of the Nephrological Service”), presents data on the state of the nephrological service of the Russian Federation as of December 31, 2023. The data covers 98% of the constituent entities (with the exception of the Chukotka Autonomous Area, the Altai Republic, Zaporozhye and Kherson re-gions), representing 99% of the Russian population. The state of the nephrology service during the height of the COVID-19 pandemic and the early “post-COVID” period has been published in previ-ous reports from 2020–2022 [2–6].

Objective. Evaluation of the clinical and economic effectiveness of the use of epoetin alfa or roxadustat in combination with iron supplements in adult patients with anemia due to chronic kidney disease (CKD) on dialysis in the Russian healthcare system.

Material and methods. Comparative review of the clinical effectiveness and safety of the use of epoetin alfa with calculation of direct medical costs was performed; pharmacoeconomic model to assess the relationship between the use of epoetin alfa or roxadustat and the financial costs of therapy for CKD patients with anemia was developed; cost-effectiveness analysis and budget impact analysis were conducted.

Results. An analysis of the literature showed that the use of roxadustat in CKD patients with anemia leads to a more rapid and significant increase in hemoglobin (Hb) levels with a lower iron requirement compared to the use of epoetin alfa. However, roxadustat also has a higher incidence of adverse events (AEs) and serious AEs (SAEs). Direct medical costs for a course of epoetin alfa per patient per year (RUB 200,792.25) were lower than for a course of roxadustat (RUB 273,653.2), with different costs of treating complications (RUB 7,597.51 and RUB 18,325.05, respectively). According to the cost-effectiveness analysis, the advantage remained with the course of epoetin alfa, the cost-effectiveness coefficients for which were: RUB 237,905.51. per year per patient who responded to therapy, and 85,081.46 rubles. per year for an increase in Hb level by 1 g/dL. For roxadustat, these values amounted to 310,264.4 rubles. per year and 106,479.84 rubles. per year accordingly. Thus, when choosing epoetin alfa, the savings will be RUB 72,358.89. or RUB 21,398.38 taking into account the response to therapy or increase in Hb level, respectively. Sensitivity analysis demonstrated the stability of the developed model to an increase in the cost of a course of epoetin alfa to +30%, a decrease in the proportion of patients who responded to a course of epoetin alfa to 23%, and decline in Hb level during treatment with epoetin alfa to 20%. The budget impact analysis showed that, with a possible cohort size of 47,000 people, increasing the proportion of patients receiving epoetin alfa from 70 to 90% while reducing the proportion of patients receiving roxadustat from 30 to 10% would reduce budget costs by RUB 684,892,928 ,64 per year. This will allow an additional 3,411 CKD patients on program hemodialysis with anemia to be treated with epoetin alfa per year (+7.25%).

Conclusion. The results of the work showed that the use of epoetin along with standard iron therapy in adult CKD patients with anemia on program hemodialysis and not previously treated with erythropoiesis-stimulating agents is clinically effective and economically preferable therapy within the Russian healthcare system.

Objective. Evaluation of the prognostic role of the Charlson comorbidity index (CCI) as a predictor of fatal outcome in a cohort of patients ≥60 years old with stage 5 chronic kidney disease (stage 5 CKD).

Material and methods. Analysis of data from 246 patients ≥60 years old with stage 5 CKD.

Results. A univariate analysis was performed, predictors of fatal outcome: age ≤65 years, CCI >5 points, diuresis ≤350 ml/day, presence of hyperhydration, predialysis creatinine levels (pdCr) ≤514 µmol/l, predialysis urea levels (pdU) >44 mmol/l, glomerular filtration rate (GFR) according to the CKD-EPI formula ≤3.1 ml/min/1.73 m². Multivariate analysis, predictors of fatal outcome: age >65 years (hazard ratio - HR=1.7, 95% confidence interval - CI 1.1–2.4), CCI >5 points (HR=3, 95% CI 2–4, 4), pdCr ≤514 µmol/l (HR=2.7, 95% CI 1.7–4.5) and pdU >44 mmol/l (HR=1.8, 95% CI 1.2–2, 9).

Conclusion. CCI can be used when choosing treatment tactics for patients aged ≥60 years with stage 5 CKD along with other generally accepted predictors of fatal outcome (pdCr, pdU, age).

Aim: comparative analysis of factors influencing the course and prognosis of multiple myeloma, depending on the involvement of the kidneys.

Material and methods. Clinical and laboratory parameters of 100 patients with multiple myeloma were studied: 50 patients with renal involvement (I group) and 50 patients without it (II group). Demographic, constitutional indicators, and treatment regimens were comparable in both groups.

Results. In patients with kidney damage, the diagnosis was established on average after 12,8±2,9 months from the onset of complaints, and in patients without kidney damage – 7,9±1,2 months (t=1,5; p>0,05). Patients with multiple myeloma and kidney damage had significantly lower hemoglobin levels and more often destructive skeletal lesions. By the myelograms, the average percentage of plasma cells in patients with kidney damage is higher than in patients without kidney damage (39,9±2,7% vs 27,6±3,1%, t=3; р<0,01). 13 (26%) patients of the first group required hemodialysis sessions, and in 9 (~70%) of them dialysis treatment was started at the time of diagnosis. In 74% of patients with kidney damage, renal function improved during chemotherapy.

Conclusion. Timely diagnosis of MM will avoid severe kidney damage, promote better renal response and improve the prognosis of the disease.

As is known, in the body of a patient receiving hemodialysis (HD), along with metabolic disorders, acid-base conditions, digestion, endocrine disorders, etc., pathological irreversible changes in the reproductive system are observed. They lose their ability to work and become disabled. Therefore, many women on HD do not experience pregnancy or have a miscarriage. In recent years, major reforms have been carried out in Uzbekistan in the healthcare system, in particular in the field of nephrology and HD. Among these reforms, special attention is paid to improving the quality and HD coverage of the country's population.

Description of the clinical case. The article describes the first successful pregnancy and natural childbirth in a patient on program HD in Uzbekistan.

The sequence of involvement of factors contributed to the pathogenesis of nephrogenic anemia (NA) begins with the development of nephrosclerosis, retention of uremic toxins and activation of inflammatory cytokines; disturbances in the oxygen sensor in the kidneys, regulation of erythropoiesis, synthesis of endogenous erythropoietin and the development of its deficiency, development of functional iron deficiency and eryptosis are secondary mechanisms for the development of NA. Understanding of these processes serves as the basis for pathogenetic therapy of NA with iron preparations and recombinant human epoetin (rhEPO), which allows achieving the target hemoglobin level in 95% of patients. Transient resistance due to complications of CKD or intercurrent diseases may develop in a significant proportion of patients. What is the role of rhEPO, iron supplements, and prolyl hydroxylase inhibitors in the treatment of resistant anemia? There is no consensus on this issue. Knowledge of the characteristics of NA resistance allows to justify therapeutic tactics, minimizing the risks of using erythropoiesis-stimulating drugs.

Asymptomatic hyperuricemia is a term traditionally applied to conditions in which serum urate concentrations are elevated, but there are no symptoms or signs of diseases associated with precipitation of uric acid crystals, such as gout or uric acid kidney disease. According to a number of studies, hyperuricemia is associated with other disorders that are not directly related to crystal deposition (including chronic kidney disease – CKD, arterial hypertension, cardiovascular, and neurological diseases). The purpose of this review was to analyze modern literature on modern concepts of the etiology, pathogenesis, diagnostic criteria for asymptomatic hyperuricemia and its role in the formation of renal dysfunction, cardiovascular and metabolic disorders.