Clinical nephrology

Background. Chronic kidney disease (CKD) is one of the leading non-communicable diseases. Modern technologies of renal replacement therapy in end-stage CKD can increase the life expectancy of patients. Improving the quality of life of patients with CKD who are on long-term renal replacement therapy by hemodialysis is an important public health issue.

Objective. To carry out a multifactorial analysis to identify medical and social factors associated with the quality of life of patients with chronic kidney disease on hemodialysis.

Material and methods. To assess the medical and social characteristics of patients with CKD on hemodialysis, a specially designed questionnaire containing 21 questions was used. Patients' quality of life was assessed using the KDQOL-SF questionnaire. Statistical data processing was carried out using the SPSS program.25. A total of 723 patients with CKD receiving hemodialysis therapy in dialysis centers in Moscow participated in the study. Collection period: August-November 2021.

Results. Low indicators of the quality of life of patients were revealed. A set of seven significant medical and social factors associated with the values of the quality of life scales was established – age, gender, financial situation, living conditions, physical activity, smoking and duration of hemodialysis, their total contribution to the variance of the quality of life scales ranged from 7 to 23.5%.

Conclusion. It is important to take into account the identified medical and social factors associated with the quality of life of patients with CKD on hemodialysis when planning and evaluating medical and organizational measures aimed at improving the quality of life of this group of patients.

An analysis of the course of chronic kidney disease (CKD) and structural modification of the left ventricle (LV) at the pre-dialysis stage of the disease is presented.

Objective. Analysis of the features of the course of CKD and LV geometry at the predialysis stage, taking into account gender differences.

Material and methods. An open prospective study included 120 CKD patients at the predialysis stage. The mean age of the examined patients was 37.4±13.2 years, and the mean follow-up period was 14 months. Patients with CKD not receiving hemodialysis were selected for follow-up. All individuals signed informed consent for therapy and follow-up. Taking into account gender differences, all examined patients were divided into 2 age-matched groups: 52 women and 68 men. Along with a general clinical examination, all patients underwent echocardiography (EchoCG) at baseline and during follow-up. Glomerular filtration rate (GFR) was calculated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula. During the study period, all patients were contacted through communication and semi-quarterly medical examinations, to which patients were invited to the clinic.

Results. At baseline, women and men did not differ significantly in age, anthropometric parameters, hemodynamics, lipid profile, electrolyte content, blood fibrinogen, daily proteinuria and GFR. The Hb level and the number of peripheral blood erythrocytes were significantly lower in women. At the same time, in the group of men, the total serum protein level was significantly lower, and creatinine – higher than in the group of women. The proportion of patients on glucocorticoid therapy was significantly higher among men (50.0 and 34.6%; p<0.05). In addition, echoCG indicators - linear dimensions of the left atrium (LA, cm), end-systolic (ESD) and diastolic dimensions (EDD) of the left ventricle (LV) - were significantly higher in men compared to women. There were no differences in the incidence of left ventricle hypertrophy (LVH) between the study groups. Initially, eccentric type LVH was the predominant type of remodeling in women (82.4%), and concentric type – in men (53.8%). During the follow-up, compared with baseline data the following indicators significantly decreased in women; erythrocyte sedimentation rate (ESR) – 15.0 (8.0;27.0) and 20.0 (10.0;33.5) mm/hour (p<0.05), fibrinogen concentration – 6.104 (4.107;6.771) and 6.216 (4.884;8.880) g/l (p<0.05), calcium level – 1.08±0.21 and 1.33±0.51 mmol/l (p <0.05) and daily proteinuria values – 2.299 (1.619;3.936) and 3.645 (1.968;6.623) g (p<0.05). At the same time, the albumin – 31.9±10.7 g/l and 27.1±10.3 g/l (p<0.05) and serum creatinine levels increased. In the group of men, there was a tendency towards a decrease in Hb level and the value of daily proteinuria, and also a significant decrease in ESR rates – 8.0 (4.0;21.0) and 16.0 (7.5;32.5) mm/hour (p<0.05) and blood triglyceride (TG) levels – 1.81 (1.18;2.36) versus 2.48 (1.75;3.43) mmol/l (p<0.05). In addition, there was a significant increase in the blood serum albumin and total protein levels. The proportion of patients with elevated C-reactive protein (CRP) levels also decreased: 8 (11.7%) and 15 (22.0%) (p <0.05) and there was an increase in creatinine concentration: 115.5 (86.5; 259.0) and 114.0 (83.5;174.0) µmol/l (p<0.05), decrease in estimated GFR – 66.2 (38.6;103.8) versus 84.9 ( 55.2;110.0) ml/min (p<0.05) and serum calcium levels – 1.16±0.36 and 1.49±0.52 mmol/l (p<0.05). A comparative analysis of the studied parameters between women and men in the dynamics of the study revealed the following. In the group of men, ESR indicators – 8.0 (4.0;21.0) and 15.0 (8.0;27.0) mm/hour (p<0.05), and blood TG concentrations – 1.81 (1.18;2.36) and 2.20 (1.64;3.24) mmol/l (p<0.05), were significantly lower, and the mean sodium and median serum creatinine levels were higher compared to those in women. In women, the number of peripheral blood red blood cells was also significantly lower. During the follow-up, the LV size turned out to be significantly higher in men compared to women: 3.40±0.49 cm and 3.22±0.35 cm (p<0.05), and concentric LV remodeling developed in 11.5% of women, which was not observed in the group of men. In women, by the end of the study, the interventricular septum (IVS) thickness significantly increased: 0.94±0.21 cm and 0.90±0.20 cm (p<0.05) compared to the initial value. Similar shifts in the IVS thickness were typical for men: 0.96±0.16 and 0.92±0.13 cm (p<0.05). In the group of women, a close direct relationship between the LV myocardial mass index (LVMI) and the systolic blood pressure – BP (r=0.676; p=0.005), diastolic blood pressure (r=0.651; p=0.005) and daily proteinuria (r=0.317; p=0.043), and an inverse relationship with estimated GFR (r=-0.410; p=0.008) were revealed Similar correlation shifts were also observed between LVMI and clinical and laboratory parameters in men, with the exception of daily proteinuria (r=0.082; p=0.506).

Conclusion. During the follow-up period, the indicators of ESR, fibrinogen concentration, blood calcium and the value of daily proteinuria significantly decreased in women, which was accompanied by an increase in the blood serum albumin and creatinine levels. In men, by the end of the follow-up period, there was a significant decrease in ESR and TG levels with a simultaneous increase in the blood serum albumin and total protein levels. The proportion of patients with elevated CRP levels decreased, and there was also a tendency towards a decrease in blood Hb concentration and the value of daily proteinuria. In addition, over the course of the study, the serum creatinine levels in men increased, which was accompanied by a decrease in the estimated GFR. Comparative analysis of data between groups revealed that ESR and blood TG levels in men turned out to be significantly lower, and the mean sodium and median serum creatinine levels were significantly higher compared to women. According to the echocardiography data during follow-up, LV ESR was significantly higher in men compared to women. During the follow-up period, both women and men had a significant increase in IVS thickness compared with the initial indicators. 11.5% of women developed concentric LV remodeling. In both groups, there was a statistically significant direct relationship between the LVMI and systolic and diastolic blood pressure, and an inverse relationship with the estimated GFR.

Background. Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disease characterized by cystic transformation of the kidneys and other organs. Nephromegaly is an absolute contraindication to kidney transplantation. Currently, the most effective strategy for surgical treatment of patients has not been determined. The use of transarterial embolization (TAE) of the renal arteries leads to a decrease in the total volume of the kidneys. Studies of the pathophysiology of polycystic kidneys in conditions of acute occlusion of the renal arteries have not been carried out, and the mechanism of reduction of total renal volume after embolization was unclear. When writing the article, information about the morphology of the kidneys in ADPKD, the use of renal TAE for the treatment of patients with polycystic kidney disease published in the PubMed databases ( https://www.ncbi.nlm.nih.gov/pubmed/), the Scientific Electronic Library of the Russian Federation - Elibrary.ru (https://elibrary.ru/) and on the websites of professional urological and nephrological associations was used. The databases were searched using the following keywords: ADPKD, TAE, renal cysts, angiogenesis. At the first stage, 35 sources no older than 5 years were found, including systematic reviews and meta-analyses that were relevant to this topic. Conference abstracts, short communications, and duplicate publications were excluded. After this, based on the relevance of the data, the reliability of the sources, the impact factors of the journals and the sequence of presentation of the material in the manuscript, 15 articles from scientific international peer-reviewed journals, practical guidelines and clinical recommendations were selected directly for citation in the article.

Clinical case. The practical part of the work is presented in the form of a description of a clinical case of a patient with ADPKD, end-stage kidney disease (ESKD), treated with hemodialysis, who underwent combined treatment: laparoscopic bilateral nephrectomy with preliminary TAE of the right kidney. A pathomorphological study of the removed native kidneys was performed. Contrasting of vessels and walls of cysts, histological examination, tonometry of cysts were performed, and a description of the mechanism of renal volume reduction in the right polycystic kidney after TAE was performed.

Results. The volume of the right kidney when calculated using manual multislice computed tomographic planimetry 1.5 months after TAE was 2190 ml; the volume of the right kidney decreased by 30% (≈916 ml). When measuring intracystic pressure in a polycystic kidney after embolization, a decrease in pressure to 10 mm Hg was noted. on average by 47.5% compared with a kidney without embolization. After the injection of a dye solution into the cyst of a removed native kidney after TAE, when the lumen of the cyst was opened, intense staining of the vascular bed with the dye was macroscopically observed. During a microscopic examination of a polycystic kidney after TAE, attention was drawn to healed areas due to renal infarction and an extensive neomicrovascular network. Small cysts completely regressed and were replaced by fibrous tissue. Drainage of intracystic fluid was carried out into neocapillaries: venules and lymphatic vessels.

Conclusion. Thus, we have practically proven the communication of cysts with a wide vascular network, which means that embolization leads to a decrease in the volume of cysts. The reduction in renal volume occurs primarily due to a series of microcirculatory events. TAE is an effective and minimally invasive technical procedure that can be used in the combined treatment of patients with ADPKD and ESKD. The combined use of renal artery TAE followed by delayed bilateral nephrectomy will improve the results of surgical treatment of patients with ESKD and ADPKD by reducing renal volume.

This article describes a clinical case of a combined anomaly of the urinary system in a nine-year-old boy with the presence of a posterior urethral valve and a large congenital bladder diverticulum, and also analyzes the genetic aspects of the formation of these pathologies. When examining the child, the clinical and genealogical method, functional research methods (ultrasound examination of the kidneys and bladder, intravenous urography and cystography, complex urodynamic study, cystoscopy), clinical and biochemical examination of blood and urine were used. The patient underwent transvesical diverticulum removal with bladder drainage using an indwelling Foley catheter to ensure low pressure wound healing and avoid persistent urine leakage. Treatment of children with developmental anomalies of the kidneys and urinary tract is carried out within the framework of a multidisciplinary approach with an individual management plan and constant monitoring of progressive chronic renal failure. The management strategy for patients with bladder diverticulum is based on clinical manifestations, and the decision to perform surgical treatment of children with bladder diverticulum is made by a team of specialists, which includes urologists, nephrologists, pediatric surgeons, pediatricians and functional diagnostic doctors.

Evaluation of the causes and mechanisms of acute kidney injury (AKI) is an urgent task of modern urology, as it leads to a better understanding of the pathology and facilitates the search for effective therapeutic strategies.

Material and methods. This article analyzes literature sources on the significance of biomarkers with proven changes in the expression level in AKI.

Results. The diversity of pathogenetic mechanisms determines the participation of many genes in the cascade of pathological reactions that lead to AKI. Genetic profiling aimed at searching for genetic determinants of AKI will provide early identification of patients at risk and personalized preventive measures in accordance with the modern model of patient-centered medicine.

Conclusion. To date, however, genetic variants of biomarkers of kidney damage and their relationship with susceptibility to AKI have not been determined, and diagnostic panels of expression of genetic biomarkers of kidney damage are not used in routine clinical practice.

The article presents the prerequisites, formation and development of ideas about the physiology of the kidneys and salt and water metabolism.

Objective. Analysis of the basic ideas about kidney function, starting from the era of the Ancient world and ending with studies of the modern period.

Material and methods. When preparing the text of this publication, articles in publications included in the RSCI and PubMed were used. The depth of the search for publications was 20 years, and a number of earlier works relevant to the research topic were also included in the review.

Results. The results on the process of formation and development of ideas about the physiology of the kidneys are presented. In the Ancient World and the Middle Ages, scientists identified the urinary function of the kidneys as the main one. In modern age, the mechanisms of kidney function began to be studied. In modern times, the morphofunctional and molecular foundations of kidney physiology have been largely studied in foreign laboratories; the role of the kidney as a homeostatic organ that regulates the balance of water and ions under the influence of neurohumoral factors has been comprehensively studied mainly by domestic authors.

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.