Vol 80, No 6 (2008)

Articles
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Types of lupus nephritis exacerbations: prognostic significance
Samokishina N.A., Kozlovskaia N.L., Shilov E.M., Varshavskiĭ V.A., Miroshnichenko N.G.
Abstract
Aim. To characterize the course of lupus nephritis (LN) in terms of demographic indices (sex, age of renal disease onset), the presence of antiphospholipid syndrome (APS) and to ascertain a prognostic role of the disease exacerbations. Material and methods. A total of 121 LN patients were followed up from 1997 to 2004 (mean duration of the follow-up 5.6 ± 6.4 years). A LN course was characterized by the presence of a complete or partial remission, exacerbation of the disease, repeated hospitalisations. Two types of exacerbations were considered: proteinuric, running with progressive proteinuria and normal renal function (type 1); functional, running with elevation of blood creatinine (type 2). Results. Exacerbations were observed in one third of the examinees, 70% of them ran with renal dysfunction. Exacerbations occurred more frequently in males than in females (50 vs 27%, respectively; p=0.08) and in patients with early onset of LN (at the age of 40 years and younger, 80 vs 60%, respectively; p<0.05). Exacerbations of type 2 occurred in males, in patients with early onset of renal damage and in APS association. It is shown that LN exacerbations, their incidence and type (a functional type) have a negative influence on renal survival of the patients. Conclusion. Identification of groups of LN patients at high risk of exacerbations and unfavourable prognostic role of exacerbations dictates the necessity of due immunosuppressive therapy for maintenance of remission.
Terapevticheskii arkhiv. 2008;80(6):10-14
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Rapidly progressive glomerulonephritis in anca-associated vasculitis: a course, treatment efficacy, prognosis
Tomilina N.A., Biriukova L.S., Egorova E.T., Sukhanov A.V., Stoliarevich E.S., Kupavtseva O.A., Fedorova N.D., Frolov A.V., Trushkin R.N., Kurenkova L.G.
Abstract
Aim. To study efficacy of ANCA-RPGN treatment with corticosteroids and cyclophosphamide or mycophenolic acid drugs. Material and methods. We treated 28patients (17 males and 11 females aged 19-71 years) with morphologically verified ANCA-associated crescentic RPGN (crescentic median 79 (63:88)%. The patients received corticosteroids and cytostatics. Results. The response to the treatment was registered in 22 (78%) patients in 8-16 weeks: a complete remission was achieved in 8 patients, a partial one - in 14 patients. In partial remission renal functions recovered incompletely (median Pсr 200 (180;255) mcmol/l) in persistence of moderate proteinuria (median 0.7 (0.6;1.3)g/day) and absence of microhematuria. Probability of the treatment success depended on severity of glomerulosclerosis and weakly depended on activity of extracapillary reaction. Severe renal failure was not an absolute predictor of treatment failure. Conclusion. In the absence of advanced nephrosclerosis early treatment with corticosteroid in combination with cytostatics can produce a positive effect in 70-80% patients with ANCA associated RPGN.
Terapevticheskii arkhiv. 2008;80(6):15-24
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Contribution of irreversible morphological changes of different renal structures to development of anemia in immune glomerulopathies
Dobronravov V.A., Sipovskiĭ V.G., Trofimenko I.I., Dobronravov A.V., Klemina I.K., Titova V.A., Sipovskaia E.B., Smirnov A.V.
Abstract
Aim. To find out correlations between severity of sclerotic affection of the glomeruli, tubules, interstitium, vessels and development of anemia in patients with glomerulopathy. Material and methods. Assay of global and segmentary sclerosis, semiquantitative morphometry of severity of atrophic tubular changes, diffuse interstitial fibrosis, vascular changes (arteriolohyalinosis, elastofibrosis and perivascular sclerosis) were made in parallel with analysis of clinical laboratory data in 276 cases of chronic primary glomerulopathy with morphologically verified diagnosis by vital renal biopsy. Results. Hemoglobin concentration and advance of anemia correlate negatively with severity of diffuse interstitial fibrosis and atrophic tubular alterations. However, no correlation was found between onset of anemia, severity of global and segmental glomerular sclerosis, the presence of vascular changes in the form of arteriolar hyalynosis, elastofibrosis of small arteries and perivascular sclerosis. Conclusion. The findings suggest that development of anemia in patients with primary glomerulopathy may be the result of structural-functional disturbances in tubular epithelium and renal stroma.
Terapevticheskii arkhiv. 2008;80(6):24-29
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Nephroprotective role of early correction of impaired nutritional status in patients with chronic disease of the kidneys at a predialysis stage
Milovanov I.S., Kozlovskaia L.V., Milovanova L.I.
Abstract
Aim. To assess the rate and clinical significance of impaired nutritional status and impact of low-protein diet on inhibition of renal insufficiency in patients of stage III-IV chronic disease of the kidneys (CDK). Material and methods. A total of 200 patients with CDK stage III-IV were randomized into three groups: group 1 consisted of 123 patients with chronic glomerulonephritis (73 with stage III and 50 with stage IV), group 2-45 patients with systemic diseases (30 with stage III and 15 with stage IV), group 3 (a comparison group) - 32 patients with CGN (17 with stage III and 15 with stage IV). Patients of groups 1 and 2 received low-protein diet (0.6 g protein kg/day) balanced by either high-calorie mix containing protein SUPRO 760 or ketosteril for 24-48 months. The nutritional status was studied by anthropometric data, absolute number of lymphocytes, levels of blood albumin and transferring, intake of protein, food calorie value according to 3-day diaries. Results. Among 200 patients impaired nutritional status was detected in 22 (11.0%) patients. More than half of them had glomerulonephritis in systemic diseases (SLE, systemic vasculitis). Only in patients with systemic diseases nutritional disorders manifested at stage III. These disorders grew with progression of renal insufficiency and were detected primarily in patients with stage IV CDK. Patients with CGN on low-protein diet for a year and longer demonstrated slowing of the fall of the glomerular filtration rate (GFR). Conclusion. Early (predialysis) use of low-protein diet balanced by addition of amino- and keto-acids and high-energy nutritional mixes has a positive influence on nutritional status of patients with chronic renal insufficiency and can inhibit GFR lowering.
Terapevticheskii arkhiv. 2008;80(6):29-33
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Nutritional status of old patients on programmed hemodialysis
Revkovskaia H.S., Denisov A.I., Borisov (Moskva) I.A.
Abstract
Aim. To study nutritional status of old patients on programmed hemodialysis. Material and methods. A total of 82 patients aged 60-88 years were divided into two groups by age: group 1 (n=41) consisted of 60-75 year olds, group 2 (n=41) included 76 year olds and older. The nutritional status (NS) was assessed by anthropometric and laboratory data, a prognostic hypotrophy index. Results. In group 1 NS was normal in 65.9% patients while in group 2 - only in 29.2%. Older patients had obesity in 21.9% cases. Conclusion. It is shown that two thirds of presenile and senile patients have abnormal nutritional status. Taking into consideration the fact that protein-energy insufficiency is an unfavourable factor affecting the patients' survival, old patients need a special control of nutritional status and its early correction.
Terapevticheskii arkhiv. 2008;80(6):33-36
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The role of major vessels remodeling in development of left ventricular hypertrophy in patients with a predialysis stage of chronic renal failure
Kutyrina I.M., Rudenko T.E., Shvetsov M.I., Kushnir V.V.
Abstract
Aim. To study correlation between development of left ventricular hypertrophy (LVH) and remodeling of major arteries at a predialysis stage of chronic renal failure (CRF). Material and methods. A total of 95 non-diabetic patients (48 males - 51% and 47 females - 49%) with stage II-III CRF entered the trial. A mean age of the patients was 46.7 years (95% CI 43.7-49.8 years). Glomerular filtration rate calculated by Cockrott-Gault formula was 37.7 ml/min (33.9-41.4 ml/min), blood creatinine level - 2.9 mg/dl (2.6-3.2 mg/dl). Arterial hypertension (AH) was registered in 96% patients, smoking - in 40%, cardiovascular hereditary burden - in 54%, hyperilpidemia - in 66%, overweight - in 60%, anemia - in 34%, hyperphosphatemia - in 45%. Echocardiography, ultrasonic dopplerography of the common carotid arteries (CCA) and common femoral artery (CFA) were performed in 83 and 37patients, respectively. Results. LVH (LV myocardium mass index >134 g/m2for males and >110 g/m2 for females) was detected in 37.3% patients. Concentric remodeling was recorded in 31.3%, concentric myocardial hypertrophy - in 19.1% patients, excentric hypertrophy - in 18.1%. Development of LVH was linked with age, high systolic and pulse blood pressure, marked renal dysfunction, anemia, elevated ESR and hyperphosphatemia. The presence of LVH correlated with increased thickness of intima-media complex (IMC) of CCA and CFA (r=0.65, p<0.01 and r=0.51, p<0.05, respectively). There was correlation between thickness of LV posterior wall and impairment of CCA elasticity (r = -0.42, p < 0.05). Conclusion. Patients with initial and moderate disorders of renal function frequently have LVH related to conventional and "renal" risk factors. A LV mass increase and structural-functional changes of major vessels strongly correlate.
Terapevticheskii arkhiv. 2008;80(6):37-41
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Anemia in diabetic nephropathy: prevalence, clinical and pathophysiological aspects
Shestakova M.V., Martynov S.A., Il'in A.V., Kniazeva A.P., Shamkhalova M.S., Trubitsyna I.P.
Abstract
Aim. To investigate detectability of anemia, its clinical and pathophysiological features in patients with diabetic nephropathy (DN). Material and methods. The trial included 1020 patients with type 1 and 2 diabetes mellitus (DM). DN was diagnosed in 50% of them. Incidence of anemia was compared in 92 DN patients in type 1 DM and in 230 patients with chronic glomerulonephritis (CGN). Concentration of erythropoietin (EP) in blood serum was measured in 94 DN patients in type 1 and 2 DM. Results. Anemia develops in type 1 and 2 DM patients free of DN and unaffected renal filtration function (glomerular filtration rate - GFR > 60 ml/min 1.73 m2) was 23.3 and 18.3%, respectively. In DN patients incidence rate of anemia depended on GFR and increased with growing severity of renal failure reaching 85.7% in GFR <30 ml/min/1.73 m2. Development of anemia in DN depended also on protein urine excretion (20.0% in normoalbuminuria, 25.7% in microalbuminuria and 48.2% in proteinuria). Anemia in DN was detected more frequently and was more severe (by hemoglobin reduction) than anemia in CGN in equal GFR. At all stages of chronic disease of the kidneys EP secretion was low normal and independent of Hb and GFR. Conclusion. In DN anemia occurs more often and is more severe than in CGN. Anemia results from inadequate production of EP by the kidneys in response to anemia. Thus, early start of its correction is necessary for improvement of quality of life and inhibition of progression of micro- and macrovascular complications of DM.
Terapevticheskii arkhiv. 2008;80(6):41-47
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Prevalence of subnormal glomerular filtration rate in patients with diabetes mellitus
Trofimenko I.I., Dobronravov V.A., Bystrova N.N., Drozdova I.V., Galkina O.V., Smirnov A.V.
Abstract
Aim. To evaluate prevalence of subnormal glomerular filtration rate (GFR) in diabetes mellitus (DM) patients with reference to albuminuria level. Material and methods. GFR by MDRD and urine excretion of protein/albumin were estimated in 851 diabetic patients (473 with type 1 DM and 378 with type 2 DM). Results. Normoalbuminuria (NAU), microalbuminuria (MAU) and proteinuria were detected in 54, 16 and 30% type 1 diabetics, respectively; 77% had subnormal GFR, in NAU 8.3% had GFR decline (<60 ml/min) corresponding to stage III-IV chronic disease of the kidneys. In MAU the latter was present in 16.4%, in proteinuria - in 62.8%. Type 2 diabetics had NAU in 33.6% cases, MAU - in 17.7%, proteinuria - in 48.7%. Subnormal GFR <60 ml/min was found in 40% cases with NAU and MAU. Most patients with proteinuria had chronic disease of the kidneys of stage III-V. In a normal creatinine concentration in blood serum subnormal GFR<60 ml/min was observed in type 1 DM in 7.6, in type 2 DM - in 33% cases. Conclusion. Prevalence of subnormal GFR in diabetic patients with NAU and MAU is rather high. This necessitates wide introduction of this index in screening, follow-up and classification of renal damage severity in DM as well as estimation of albuminuria/proteinuria.
Terapevticheskii arkhiv. 2008;80(6):48-52
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Lupus nephritis as a factor of atherosclerosis risk in patients with systemic lupus erythematosus
Serikova S.I., Kozlovskaia N.L., Shilov E.M.
Abstract
Aim. To investigate early atherosclerosis (AS) risk factors in patients with systemic lupus erythematosus (SLE) in respect to the presence of lupus nephritis (LN) and antiphospholipid (APL) antibodies. Material and methods. We analysed case histories of 137 SLE patients observed in E.M. Tareev clinic from 1970 to 2006. AS manifestations were studied by echocardiography, ultrasonic dopplerog-raphy of the peripheral vessels, x-ray methods. AS was considered early if it arose at the age under 55 years. Patients with chronic renal failure were not included in the study. Results. AS development was seen in 54 (45%) patients, early symptoms appeared at the age of 25-68 years (mean 54 ± 10 years). In 37 (31%) patients AS symptoms manifested at the age under 55 years. Significant factors of early AS risk were age, hyperlipidemia, arterial hypertension, menopause for women, APL antibodies circulation, stage IV chronic disease of the kidneys, hyperuricemia, higher blood creatinine, mean dose of prednisolone over 15 mg/day, frequent elevation of the level of C-reactive protein. A direct correlation between lupus nephritis or nephrotic syndrome (NS) and early AS was not found. In LN hyperlipidemia occurred more often (p=0.055), lipids level and NS were not related during its remission. LN patients developed AS more frequently, had lower complement concentration in the end of the study, were treated with prednisolone more intensively than patients free of renal disease (p<0.05). Conclusion. Early AS develops in more than one third of SLE patients. Main risk factors of early AS are conventional ones and APL antibodies, persistence of chronic inflammation, decreased glomerular filtration rate, prednisolone therapy. LN influence on the process of atherogenesis in SLE may be mediated and caused by high rate of other risk factors.
Terapevticheskii arkhiv. 2008;80(6):52-58
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Long-term outcomes and formation of chronic disease of the kidneys in patients with a history of hemorrhagic fever with renal syndrome
Dudarev M.V., Pimenov L.T.
Abstract
Aim. To evaluate renal function, persistence of renal dysfunction and probability of chronic renal pathology in convalescents of hemorrhagic fever with renal syndrome (HFRS). Material and methods. A total of 370 HFRS convalescents were examined with estimation of renal functional reserve, albuminuria, uric acid clearance, activity of urine N-acetil-beta-D-hexosaminidase in the urine, 18-h deprevation test, duplex scanning of renal vessels. Correlation between prevalence of chronic renal failure in Udmurtia and HFRS incidence was analysed. Results. Glomerular and tubular dysfunctions in HFRS convalescents (intraglomerular hypertension, albuminuria, regress of a concentration ability of the kidneys, impairment of tubular transport) are characterized by persistence in the presence of renal hypoperfusion and hypoexcretory hyperuricemia. 13% convalescents developed chronic disease of the kidneys (CDK) which clinically presented as chronic tubulointerstitial nephritis. HFRS may contribute to formation of population of patients with chronic renal failure in the territory of active natural foci. A significant positive correlation was registered between mean annual levels of HFRS morbidity and prevalence of chronic renal failure in different regions of Udmurtia. According to clinical data, chronic renal failure develops in patients who earlier have suffered from renal disease. Conclusion. Persistance of renal dysfunctions in HFRS convalescents and possible onset of chronic disease of the kidneys necessitate active follow-up of the disease convalescents.
Terapevticheskii arkhiv. 2008;80(6):59-62
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Estimated methods of predicting risk of analgetic interstitial renal disease
Batiushin M.M., Dmitrieva O.V., Terent'ev V.P., Davidenko K.S.
Abstract
Aim. Screening of renal pathology and investigation of its dependence on intake of metamisol, the risk of nephritis associated with metamisol. Material and methods. The study included 1446 inpatients (mean age 49.63 ± 0.43 years, 690 males - 48%, 756 females - 52%). Analysis of the urine, tests for urea, blood creatinine, estimation of glomerular filtration rate were made. Metamisol doses and duration of analgetic treatment were controlled in 658 patients. Statistical processing was made with Statistica 6.0 soft. Results. Of 1446 examinees, 346 (23.9%) patients took analgetics. Out of 98 patients treated with metamisol, 34(34.7%) had pathology of urinary sediment, 18 (18.4%) had suppression of renal function (RF) while in patients untreated with analgetics this percentage was 7.4 and 16.1%, respectively, p < 0.05. In intake of metamisol from 0.5 to 5.0 kg and more changes in urine analysis parameters and regress of RF were more prominent than in intake up to 0.5 kg (p<0.05). Application of nonlinear logistic regression analysis provided equations of logistic regression making it possible to assess probability of changes in urine analysis and renal function decline depending on the drug dose and duration of its intake. Conclusion. Inpatients often take analgetic drugs, especially metamisol. Its high doses are associated with risk of renal function decline and pathology of urinary sediment. Equations of calculation of renal affection risk in administration of metamisol are presented.
Terapevticheskii arkhiv. 2008;80(6):62-65
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Changes in fatty acids content in blood red cells of patients with iron-deficiency anemia treated with sorbifer and mildronate
Goncharova E.V., Govorin A.V.
Abstract
Aim. To study fractional composition of red cell membrane (RCM) lipids in patients with severe iron-deficiency anemia (IDA) complicated by myocardiodystrophy prior to treatment and after 1-month combined treatment with sorbifer and mildronate. Material and methods. Fatty acid composition of RCM lipids was studied in 12 patients with severe chronic posthemorrhagic IDA complicated by myocardiodystrophy and in 15 healthy subjects. Extraction of lipids from blood red cells and methylation of fatty acids were performed according to K.M. Sinyak et al. (1976). Relative content of fatty acids was determined at chromatography. Results. The study detected increased content of saturated fatty acids, especially palmitic and decreased content of unsaturated fatty acids especially fraction of omega6-polyunsaturated fatty acids: arachidonic and gamma-linolenic. Conclusion. Sorbifer in combination with mildronate improved fatty acid composition of blood red cells in patients with iron-deficiency anemia.
Terapevticheskii arkhiv. 2008;80(6):65-68
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Bilateral stenosis of renal arteries in a patient with primary antiphospholipid syndrome following hemolyticouremic syndrome (a case report and review of literature)
Kozlovskaia N.L., Bobrova L.A., Zakharova E.V., Khafizova E.I., Gagarina N.V., Miroshnichenko N.G.
Terapevticheskii arkhiv. 2008;80(6):69-73
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Acute renal failure as the first symptom of primary renal lymphoma
Prokopenko E.I., Shcherbakova E.O., Koshelev R.V., Vatazin A.V., Dudina G.A., Stashuk G.A., Vorontsova S.V., Stoliarevich E.S.
Terapevticheskii arkhiv. 2008;80(6):73-76
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Loop diuretics in the treatment of edema: torasemide potentials
Fomin V.V., Moiseev S.V., Russkikh A.V.
Terapevticheskii arkhiv. 2008;80(6):77-80
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Resistent arterial hypertension
Chazova I.E., Fomin V.V.
Terapevticheskii arkhiv. 2008;80(6):80-85
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The role of matrix metalloproteinases in pathogenesis of renal disease
Bobkova I.N., Kozlovskaia L.V., Li O.A.
Terapevticheskii arkhiv. 2008;80(6):86-90
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Immunopathological acute poststreptococcal glomerulonephritis (AGN): analysis of development mechanisms
Totolian A.A., Burova L.A., Nagornev V.A., Pigarevskiĭ P.V.
Terapevticheskii arkhiv. 2008;80(6):90-95
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