Том 16, № 3 (2024)

Objective. Evaluation of the effects of sodium-glucose cotransporter type 2 inhibitors (SGLT-2 inhibitors) on the incidence of acute kidney injury (AKI) in patients with decompensated chronic heart failure (CHF) during 5 days of inpatient treatment.

Material and methods. The study included 119 patients with decompensated CHF. Patients were randomized into 2 groups: the control group (loop diuretic therapy) and the main group (combination therapy with SGLT-2 inhibitors and loop diuretics). According to the study protocol, the blood plasma creatinine level with the calculation of the glomerular filtration rate (GFR), daily diuresis and natriuresis were determined.

Results. Against the background of the therapy, from the 2nd day of the study, the level of diuresis in the main group was significantly higher than in the control group (1342.83±159.74 versus 1250.17±134.53; P<0.001). By the 5th day of follow-up, the chance of developing AKI according to the AKIN (OR=5.48, 95% CI 2.22–13.54) and RIFLE (OR=2.45, 95% CI 1.45–5.22) criteria was higher in the control group. At the same time, in the main group, the RIFLE criteria had higher sensitivity, and AKIN – higher specificity. In patients with a low increase in natriuresis (≤90.0 mmol/day), the risk of developing AKI increased by the 5th day of follow-up (OR=5.44, 95% CI 2.40–12.30; P<0.001). The risk of deterioration in GFR was almost 2 times higher in the control group (OR=0.42, 95% CI 0.19–0.93).

Conclusion. Against the background of therapy for CHF decompensation with loop diuretics and SGLT-2 inhibitors, the risk of developing AKI according to AKIN and RIFLE criteria significantly decreased. The AKIN and RIFLE criteria had different sensitivity and specificity, which requires the simultaneous use of both criteria for the diagnosis of AKI. With the use of SGLT-2 inhibitors, the risk of deterioration of SCF decreased, and a high increase in natriuresis was associated with a lower risk of AKI, which proves the nephroprotective properties of SGLT-2 inhibitors in patients during CHF decompensation.

Background. Intensive therapy of acute renal failure (ARF) in children is one of the most difficult problems in pediatrics, since it involves a complex solution to the problems facing the doctor, requiring both conservative treatment and the use of invasive (hence, aggressive) methods of renal replacement therapy.

Objective. Evaluation of the effect of intensive therapy on changes in the circadian rhythm of stroke output (SO) depending on age.

Material and methods. Data on hourly monitoring of body temperature in 33 children aged 6 months to 18 years with acute renal failure who were admitted to the ICU of the NMCC with oligo-anuria were examined. All patients underwent hemodialysis (HD) under the control of hemodynamics, acid-base status, respiratory system parameters, and received supportive, antibacterial, anti-inflammatory, syndromic corrective intensive therapy.

Results. On admission in the ICU of the NMCC, in 33 children aged from 6 months to 18 years with acute renal failure with oligo-anuria, the circadian rhythm mesor indicators of SO did not differ significantly from age standards. Hourly SO data in the average circadian rhythm of SO corresponded to age-related values. There were no significant differences in the SO indicator between daytime and night hours. Fluctuations in the amplitude of the circadian rhythm occurred in a periweekly manner.

Conclusion. In groups 2 and 1, the periweekly biorhythms of SO were more deformed. The longest inversion of the circadian rhythm was found in children of group 1, which indicated an increased risk of developing acute decompensation of cardiac function in children under 3 years of age.

Background. Kidney transplantation is the gold standard for treating patients suffering from end-stage renal failure. The main problem, which is typical for all countries, is the shortage of donor organs. Thus, an imbalance between the number of recipients in need of a kidney transplant and the number of available donor organs develops, which increases and thereby significantly limits the possibilities of using this type of treatment. In order to increase the pool of donor organs, there are current trends towards reducing the requirements for a transplant. In this regard, the number of transplanted kidneys from elderly donors, as well as after resection for identified tumors, is increasing.

Material and methods. When writing the literature review, data on modern requirements for a donor organ during kidney transplantation, published in the databases PubMed (https://www.ncbi.nlm.nih.gov/pubmed/), Scientific Electronic Library of the Russian Federation - eLibrary.ru (https ://elibrary.ru/) and websites of professional endourological associations were used. The databases were searched using the keywords “kidney transplantation”, “renal cell carcinoma”, “elderly donor”. At the first stage, 93 sources no older than 5 years were found that were relevant to the topic of the review. 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, 36 articles in scientific international peer-reviewed journals, practical guidelines and clinical recommendations were selected directly for citation in the review.

Results. Kidney transplantation has proven advantages over hemodialysis. The main groups through which it is planned to increase the number of donor organs include elderly people and donors with both newly diagnosed and previously established renal cell carcinoma (RCC). The disease-free median follow-up in the recipient group was 69 months, and graft survival with tumors up to 4 cm after 5 years was 93%. The use of ex vivo resection of a donor kidney with a tumor is justified in a group of patients with numerous concomitant diseases who will not be able to survive to the stage of kidney transplantation on a standard waiting list. The use of donor kidneys from elderly patients and donors with an incidental diagnosis or history of RCC in combination with chronic use of immunosuppressive therapy increases the risk of graft tumors. However, despite this, the advantages of using this group of donors with the growing need for kidney transplants in patients with end-stage renal failure, the undeniable advantages of transplantation in terms of survival and quality of life over other types of renal replacement therapy, prevail over the possible risks for the recipient and make this direction is promising. Despite the existing differences in the interpretation of risk categories, all modern guidelines unanimously recognize that kidney tumors <4 cm in diameter (stage pT1a) with Fuhrman risk grade I to II, despite a certain risk, can and should be used for transplantation. Transmission of RCC through a transplanted kidney was quite rare (0.015 to 1%).

Conclusion. In recent decades, against the backdrop of a shortage of transplants, there has been a steady trend towards the use of “recovered” kidneys and elderly donors to increase the pool of donor organs. At the same time, the risk of developing RCC of the transplant significantly increases, which should lead to a revision of the frequency of screening of the transplanted kidney, as well as the development and improvement of organ-preserving techniques in identifying these tumors.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a systemic autoimmune disease characterized by the development of necrotizing inflammation in small blood vessels with damage to various organs and systems. Glucocorticosteroids (GCS) in combination with rituximab or cyclophosphamide are recommended as a pathogenetic therapy for ANCA vasculitis and help restore kidney function and reduce mortality. However, the use of these drugs is associated with certain side effects, primarily this concerns caution with respect to GCS. In this regard, there is a constant search for drugs that could ensure both the achievement of clinical remission of ANCA vasculitis (as the main goal of therapy) and a reduction in the dose, and, ideally, the cancellation of GCS. Based on the data obtained on the role of the alternative complement pathway in the pathogenesis of ANCA vasculitis, avacopan, C5a receptor inhibitor, was proposed for its treatment. In a clinical trial involving patients with ANCA-associated vasculitis, avacopan was non-inferior in achieving remission at week 26 and superior to the GCS therapy group in achieving sustained remission at week 52. All patients in the study also received cyclophosphamide or rituximab. Avacopan is recommended by KDIGO 2024 for inclusion in the induction phase of therapy to reduce the dose of GCS in patients with ANCA glomerulonephritis.

Description of the clinical case. The article presents a case of a patient with granulomatosis with polyangiitis (GPA), who was diagnosed at an advanced stage of the disease, with damage to vital organs and an extremely high risk of death. The severity of the patient's condition required mechanical ventilation with subsequent initiation of venovenous extracorporeal membrane oxygenation (ECMO), as well as renal replacement therapy. Therapy was initiated with a series of plasma exchange sessions, pulse therapy, followed by a transition to oral GCS. Taking into account the severity of glomerulonephritis and infectious complications, the decision of the council was to initiate therapy with avacopan, a drug unregistered in the Russian Federation (in combination with cyclophosphamide and rituximab).

Results. After 8 months from the start of pathogenetic therapy, the patient, who was constantly taking a minimum dose of GCS and avacopan, clinically demonstrated remission of GPA in relation to extrarenal manifestations and partial remission of glomerulonephritis.

Infections caused by traditional gram-negative microflora from the enterobacteria family are not something special in patients who are kidney transplant recipients and receive long-term immunosuppressive therapy. However, in some cases, the immunocompromised state of patients in this group leads to the development of rather rare zoonotic infections, such as campylobacteriosis, the source of which are domestic animals, and can initiate the development of a severe systemic inflammatory process with pronounced organ dysfunction. At the same time, continued contact with infected domestic animals in the future can lead to a relapse of the infectious process, even after the initial cure. The article describes an illustrative clinical case of severe recurrent campylobacteriosis with a repeated episode of infection a year after the primary one, with the development of a pronounced systemic inflammatory reaction and dysfunction of the kidney transplant.

The review article presents current information on the prevalence and diagnosis of polycystic kidney disease (PKD). Estimated prevalence of autosomal dominant polycystic kidney disease (ADPKD) indicates that the estimated number of patients in different countries varies from 1 case per 400–1000 newborns, and in the general population 1 per 2459 (in the UK), 1 per 2700–4000 (in Japan), 1 per 1111 (in France). In addition, according to the European Renal Association (ERA), the prevalence of this pathology in 19 European countries was 1 case per 2525 (i.e. no more than 5 cases per 10 thousand inhabitants). Autosomal recessive polycystic kidney disease (ARPKD) is less common, and the clinical course and prognosis are much more severe than with ADPKD. The clinical picture of ARPKD manifests itself in perinatal period or childhood.

In Tajikistan, despite the increase in the incidence rate and the importance of this problem, many aspects of ARPKD, such as prevalence, diagnosis, clinical symptoms, and features of the course of the disease, remain unclear and contradictory. Moreover, clinical course variants of the disease with low therapy efficiency and often leading to early disability and mortality are increasingly observed. Thus, there is a noticeable underestimation of the real prevalence of APKD, so a significant number of patients (probably only with a mild or moderate form of the pathology) remain undiagnosed. The most informative visual diagnostic methods include ultrasonography, computed tomography and magnetic resonance imaging, as well as genetic analysis, which can be used to obtain more accurate data that have prognostic value.

The article discusses the draft amendments proposed to be introduced into the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (hereinafter referred to as the Law on Protecting the Health of Citizens) and the Law of the Russian Federation of 02/07/1992 No. 2300-1 “On the Protection of Consumer Rights” (hereinafter referred to as the Law on the Protection of Consumer Rights), which proposes to separate the concepts of “medical service” and “medical care”.

The author identifies the general problem of the lack of separation of the two concepts. The law enforcement practice and problems of extending the provisions of the Law on the Protection of Consumer Rights to paid medical services and free medical care are analyzed. The contradictory and formal approach of law enforcement agencies when qualifying the actions of doctors accused of committing crimes, and the courts when making decisions in civil cases is shown. The social significance of the medical care provided to citizens is emphasized.

Conclusion. Based on the results of the analysis, it can be concluded that it is possible to amend the current legislation in order to stop the extension of the Law on the Protection of Consumer Rights to free medical care, eliminate the formal approach of courts and law enforcement agencies in resolving civil and criminal disputes and qualify the actions of doctors accused of committing crimes, as well as in order to create uniformity in judicial practice.

Catheter-associated infections are important risk factors for catheter loss and peritonitis. The Guidelines 2023 update revise and clarifiy the definitions and classifications of catheter exit site infection and tunnel infection. The new target for overall catheter exit site infection rate is 0.40 or fewer episodes per year, based on risk. The recommendation for topical antibiotic cream or ointment to the catheter exit site has been downgraded.

The new guidelines include clarification on exit site dressing and updated duration of antibiotic treatment, with an emphasis on early clinical monitoring to guide duration of therapy. In addition to catheter removal and reinsertion, other catheter interventions are suggested, including outer cuff removal or shaving, and exit site relocation.