卷 15, 编号 4 (2023)

Objective. Evaluation of the relationship between serum myostatin levels and indicators of protein-energy malnutrition (PEM) in patients on program hemodialysis (PHD).

Material and methods. 645 patients on program HD were examined, among them 300 men and 345 women aged 56.8±12.8 years. All patients received treatment with program HD for 8.4±5.3 years. Assessment of nutritional status for the purpose of diagnosing PEM was carried out using the method proposed by ISRNM (International Society of Renal Nutrition and Metabolism). The blood serum myostatin level was determined by a method based on the principle of competitive enzyme immunoassay using mono- and polyclonal antibodies to myostatin using a commercial kit “Myostatin ELISA” (Immunodiagnostik, Germany) in accordance with the manufacturer’s instructions. Reference values for myostatin were 11–44 ng/ml.

Results. The prevalence of PEM, determined by the ISRNM method, was 24.9% (160 patients). The mean myostatin values in patients without signs of PEM were 31.2±16.2 ng/ml, and in patients with PEM – 76.7±25.5 ng/ml (P<0.0001). Patients with elevated myostatin levels had statistically significantly lower values of PEM indicators (body mass index, skeletal muscle mass index, as well as total protein, albumin, prealbumin, total cholesterol, transferrin and the number of blood lymphocytes) than patients with normal myostatin levels. At the same time, no statistically significant changes in body fat mass parameters depending on the myostatin level were detected. During the study, no significant relationship was found between the adequacy of the HD dose (spKt/V) and myostatin levels, which is confirmed, in particular, by the value of the Spearman correlation coefficient (Rs = 0.063; P = 0.106). In addition, there was no connection between the myostatin level and the duration of HD (Rs = 0.056; P = 0.151).

Conclusion. The prevalence of PEM, determined by the ISRNM method, in patients on program HD was 24.9%. An increase in the blood serum myostatin level may be an important pathogenetic link in the development of PEM in patients on program HD, mainly due to a negative effect on the patient’s muscle tissue.

Background. Nephrotic syndrome (NS) is a common kidney disease in childhood. The disease is characterized by massive proteinuria, hypoalbuminemia and edema. Edema is one of the main characteristics of NS, but its pathogenesis is still not fully understood.

Objective. Assessment of the state of intravascular volume using echocardiography parameters.

Material and methods. The study included 80 children with different types of NS, aged from 2 to 18 years. Intravascular volume status was assessed by determining the inferior vena cava index, inferior vena cava contractility index, left atrium diameter and aortic annulus diameter.

Results. In 28 patients, the mean index of the inferior vena cava contractility was 11.94±7.80%, the mean diameter of the left atrium was 22.09±12.42 mm/m2, the diameter of the aortic ring was 25.34±5.64 mm. In the remaining 52 patients, the mean index of the inferior vena cava contractility was 13.98±5.21%, the mean diameter of the left atrium was 27.78±6.99 mm/m2, the diameter of the aortic ring was 20.23±3.72 mm.

Conclusion. Echocardiographic parameters such as inferior vena cava contractility index, left atrial diameter, and aortic annulus diameter were the best predictors of body fluid volume status in NS and were a useful guide for assessing intravascular volume status in children. This study also showed that a wide range of patients with NS are normovolemic or hypervolemic.

Background. Atypical hemolytic uremic syndrome (aHUS) is a chronic systemic disease of genetic origin, which is based on uncontrolled activation of the alternative complement pathway, leading to generalized thrombus formation in the microvasculature (complement-mediated thrombotic microangiopathy - TMA). A typical triad of aHUS symptoms includes consumptive thrombocytopenia, nonimmune hemolytic anemia, and acute kidney injury. The predominant damage to the kidneys is probably associated with the increased sensitivity of the fenestrated glomerular endothelium to such damage. At the moment, the diagnosis of aHUS is one of the diagnoses of exceptions and does not have specific pathognomonic signs. It is established on the basis of the clinical picture of the disease after excluding other forms of TMA, both primary and secondary.

Objective. Demonstration of the difficulties of diagnosing and treating aHUS using a clinical example.

Description of the clinical case. In patient I., 27 years old, since 2016, proteinuria up to 1 g/day with “empty” urinary sediment and episodes of increased blood pressure were recorded, which was interpreted as chronic glomerulonephritis. Symptoms characteristic of aHUS: anemia, decreased platelet levels, and acute kidney injury of the graft developed in the patient in the early postoperative period. However, nonspecific symptoms were regarded as consequences of significant blood loss during surgery and delayed graft function. Discussion of the diagnosis of TMA became possible primarily due to the results of a morphological study of the graft tissue and was difficult due to the development of postoperative complications and the current septic condition.

Conclusion. It is extremely important for doctors to be aware of the disease and the possibilities of its diagnosis, because a timely confirmed diagnosis of aHUS and the initiation of targeted therapy can significantly improve or completely restore the function of the affected organs.

Objective. Comparison of the long-term results of the use of cyclosporine (CsA) and tacrolimus (TL) in kidney transplant recipients (KTR), obtained in City Clinical Hospital № 52 of the Moscow Healthcare Department, with a systematic analysis of published studies on this topic.

Material and methods. In a 30-year (1989–2018) retrospective study conducted from 2007 to 2012, there were statistically significant differences in estimated glomerular filtration rate (eGFR, ml/min/1.73 m2) between the two KTR groups receiving CsA or TL respectively. Patients receiving TL were younger, more male, and had better survival (p<0.05). We performed a meta-analysis to compare the effects of CsA and TL on GFR and survival. The electronic PubMed, MEDLINE, Scopus and the Cochrane Library databases were searched for studies comparing maintenance immunosuppression options based on TL and CsA in the experimental and control groups, respectively, for at least a year after kidney allotransplantation. The primary outcome of the study was patient survival, the secondary outcome was renal graft function, determined by creatinine clearance (GFR, ml/min) according to the Rehberg test or the Cockcroft-Gault formula, or by eGFR in the CKD-EPI, MDRD, Nankivell equation. Meta-analysis of proportions was performed using the Freeman–Tukey transformation to calculate weighted summary proportions from a fixed and random effects model. Odds ratios (ORs) were used to assess dichotomous variables, and mean differences (MDs) and 95% confidence intervals (CIs) for both variables were used for continuous variables. Of the total 678 studies found, 16, including our own, were included in the systematic review and meta-analysis, with a total of 12,181 patients (treatment n=6504 and control n=5677 groups).

Results. The meta-analysis included 12 randomized and 4 non-randomized controlled trials. There were no differences between the two groups in age, sex, creatinine level, or patient survival. GFR was significantly higher for TL-based immunosuppressive regimens than for CsA in the fixed model (HR=0.451, 95% CI 0.39 to 0.5; p<0.001) and in the random model (HR=0.641, 95% CI from 0.286 to 0.996; p<0.001). Meta-analysis data on GFR were significantly heterogeneous: I2=96.96%, 95% CI 95.8 to 97.79, Q test; p < 0.0001, however, Begg's test (p=0.815) and Egger's test (p = 0.456) do not suggest the presence of publication bias in this case.

Conclusion. A meta-analysis showed that, compared with CsA, TL has an advantage only in its effect on GFR. Differences in baseline GFR determination and creatinine calibration may likely explain the heterogeneity of findings in this meta-analysis. These factors should be considered by researchers and clinicians when interpreting GFR estimates. In this regard, the use of a single eGFR for KTR is relevant.

Chronic kidney disease (CKD) is a serious, rapidly growing global health problem. The etiological heterogeneity of CKD, continuously increasing volumes of patient data, the need for simultaneous monitoring of a number of vital indicators, annually increasing requirements for the quality of medical care - this is an incomplete list of what makes it necessary to implement modern medical information systems (MIS), including elements of artificial intelligence/medical decision support systems (AI/CDSS) into the practice of a nephrologist. In our review, we tried to describe modern achievements in the digitalization of nephrological care in the world using MIS with AI to solve a wide variety of problems.

Background. The result of surgical treatment of kidney cancer (KC) is determined not only by cancer-specific survival, but also by impaired renal function, which may occur in the patient as a concomitant pathology or develop after surgery, especially afterf radical nephrectomy. Timely diagnosis and prevention of renal dysfunction progression in patients with KC is an urgent task of modern onconephrology.

Objective. This literature review analyzes the functional results of surgical treatment of KC.

Material and methods. A review of published scientific literature in the Pubmed, Elsevier, Springer, and Elibrary databases for 2018–2023was conducted.

Results. A review of the scientific literature showed that patients with KC often have concomitant chronic kidney disease. In addition, malignant kidney tumors themselves are associated with an increased risk of nephropathies.

Conclusion. The use of organ-sparing operations for KC makes it possible to preserve renal function to a greater extent at the initial (preoperative) level, prevent the development or progression of existing renal dysfunction and improve the functional outcomes of treatment and the quality of life of patients.