Search

Of all cases of acute kidney injury (AKI), 45-70% are associated with sepsis. Lethality in sepsis-associated AKI requiring renal replacement therapy (RRT) ranges from 40 to 50%, and in AKI combined with other organ dysfunctions - 60-80%. In order to improve the results of treatment of sepsis and septic shock, various methods of extracorporeal detoxification (ECD) have been developed. The effectiveness of these methods is controversial. In the treatment of sepsis, RRT is used not only to replace the impaired detoxification function of kidneys, but also to remove excess cytokines from the systemic bloodstream. The literature describes mainly positive results of the use of dialyzers with an adsorbing membrane, however, these data do not have the necessary degree of evidence. Currently, there are no clear criteria for the initiation of RRT, its duration and doses, the choice of methodology determined by specific clinical and laboratory parameters, and staging of this therapy. All this highlights the need for further research in this field.

Lipoprotein(a) [Lp(a)] is a subclass of lipoproteins consisting of a cholesterol-rich low-density lipoprotein (LDL) particle with a single apolipoprotein B100 molecule covalently bound (via a disulfide bridge) to a unique hydrophilic high-glycosylated protein called apolipoprotein a [apo(a)]. To date, there is sufficient evidence to consider an increase Lp(a) level as a causal and independent risk factor for cardiovascular disease and calcifying aortic valve stenosis. Plasma concentration of Lp(a) can vary in a wide range, which is mainly determined by genetic factors. Up to 30 % of the world's population has an elevated Lp(a) level, but this category of lipid disorders has not been currently receiving adequate attention. Determining the Lp(a) plasma concentrations is not included in the standard lipid profile, so a significant number of individuals with hyperlipoproteinemia(a) who could potentially benefit from treatment remain undiagnosed. Certain significant obstacles are still associated with the lack of standardized assay for measuring Lp(a) concentrations and a consensus on its optimal levels in blood plasma. Although some limited but statistically significant data suggest a possible benefit of lipoprotein(a) lowering on cardiovascular outcomes, no specific recommendations were made for the management of that dyslipidemia in the latest guidelines. Plasma Lp(a) levels reflect a balance of Lp(a) synthesis, which occurs in the liver, and catabolism, which is thought to involve the kidney. Lp(a) concentration begins already to increase in the earliest stages of chronic kidney disease, and patients with nephrotic syndrome have a four-fold elevated Lp(a) in comparison to healthy individuals. However, it remains unclear if elevated Lp(a) levels affect cardiovascular risk in patients with kidney diseases. This article summarizes the main data regarding the relationship between Lp(a) content, impaired renal function, and an increased risk of adverse cardiovascular events.

The choice of non-drug methods for the treatment of systemic scleroderma is currently very limited. Several studies show that extracorporeal photochemotherapy can improve kidney and lung function and reduce skin fibrosis in patients with systemic scleroderma. We studied the dynamics of clinical and laboratory parameters in patients with systemic scleroderma with an assessment before and after 12 months against the background of complex treatment, which included programmed extracorporeal photochemotherapy. Indications for inclusion in the study was the ineffectiveness of standard therapy with glucocorticoids and cytostatics or the impossibility of their use, as well as signs of an unfavorable prognosis of the disease: diffuse form, high skin count (14), rapid progression with a significant initial decrease in the glomerular filtration rate, forced vital capacity, high immunological activity (high titer of antinuclear factor and positivity for antibodies to Scl-70). When evaluating the results of complex treatment, a good clinical effect was observed in all patients: the induration of the skin decreased, the functionality of the lungs and kidneys increased. A significant decrease in the disease activity index was noted. These positive changes were the basis for a decrease in the daily dose of glucocorticoids. Significantly significant changes were observed in a decrease in the immunological activity of the disease: levels of C-reactive protein, erythrocyte sedimentation rate and immunoglobulin G, antinuclear factor titer and all types of circulating immune complexes. The results of our study confirm the data of other studies that demonstrated the positive effect of extracorporeal photochemotherapy as a component of the complex treatment of systemic scleroderma.

The results of complex treatment with the programmed procedures of extracorporeal photopheresis and methotrexate in patients with psoriatic arthritis for 12 months are presented. It has been established that program extracorporeal photopheresis in combination with basic therapy with methotrexate in patients with psoriatic arthritis have a significant effect on the relief of articular syndrome (reduction of morning stiffness, pain intensity, joint swelling). It was revealed that the inclusion of programmed extracorporeal photopheresis and methotrexate in the complex treatment of psoriatic arthritis reduces the level of circulating low molecular weight, medium molecular weight and high molecular weight immune complexes and in most cases leads to clinical and immunological remission. This is confirmed by a decrease in complaints of the severity of articular syndrome and a decrease in the clinical and laboratory activity of the disease (a significant decrease in the level of C-reactive protein, erythrocyte sedimentation rate). A scheme has been developed for the programmed use of extracorporeal photopheresis procedures in the complex treatment of psoriatic arthritis, which consists of 2 procedures every other day with an interval of 2,5-3 months for 12 months. Combined therapy with the programmed application of extracorporeal photopheresis procedures and methotrexate prolongs the period of disease remission and can be recommended for patients with psoriatic arthritis with high activity, insufficient effect of basic therapy and intolerance to higher doses of immunosuppressive drugs.

The effectiveness of antibacterial therapy is a critical factor to improve treatment outcomes in sepsis patients. Impaired renal function and renal replacement therapy lead to a significant change in the pharmacokinetic parameters of most intravenous antibacterial drugs, which in many cases is accompanied by insufficient or excessive concentration in the blood which results in antibacterial therapy failure. The article presents current views and describes the current problems of antibacterial therapy for sepsis during the use of extracorporeal detoxification methods. The objective : to analyze publications on antibacterial therapy of sepsis during the extracorporeal detoxification. Results: the most accessible and effective method for solving the problem of inadequate dosage of antibiotics when using extracorporeal detoxification is to develop local protocols based on the results of pharmacokinetic studies.

IgG4-related disease (IgG4-RD) currently is considered as a chronic fibroinflammatory immune-mediated multisystemic condition of unidentified etiology, which can imitate a wide range of malignant, infectious, rheumatologic, and other diseases. It can affect almost any organ system in the body synchronously or sequentially, but the most often affected are the pancreas, hepatobiliary tract, periorbital structures, salivary glands, kidneys, and lymph nodes. The most frequent renal manifestations of IgG4-RD is IgG4-related tubulointerstitial nephritis. Membranous nephropathy is the most common glomerular disease accompanied by IgG4-RD. Regardless of the organ localization, patients with IgG4-RD are characterized by elevated serum IgG4, but this laboratory abnormality is not specific and can be changed in other diseases. In all suspected cases of IgG4-RD the diagnosis should be confirmed by histological examination. Characteristic pathologic features include diffuse or focal lymphoplasmacytic infiltration with prominent IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. Patients with IgG4- RD usually have an excellent clinical response to glucocorticoids, but relapse rates after steroid withdrawal are high, which may require additional use of immunosuppressants or rituximab. Due to the low prevalence and multitude of clinical manifestations the disease often remains underdiagnosed on time. This case report describes middle-aged patients with a history of chronic recurrent pancreatitis complicated by the nephrotic syndrome. Kidney biopsy showed membranous nephropathy and diagnosis IgG4-RD with multiorgan involvement was made. Partial remission was achieved on corticosteroid therapy. The presented case clearly demonstrates the difficulties of diagnosis and treatment of IgG4-RD. IgG4-related membranous nephropathy should be included in the differential diagnosis for patients with nephrotic syndrome accompanied by multiorgan dysfunction.

Relevance. Discussion of the criteria for decision making “amputation vs. preservation”, when viability of the extremity is uncertain, has been continuing. The case description. The lower extremity of a serviceman was injured by a caterpillar tractor. The severity of the damage was determined by the following conditions: open segmental fracture of the femoral diaphysis, 5 cm traction-compression damage of the popliteal artery, acute thrombosis of the popliteal and tibial arteries, sciatic nerve damage, circular detachment of the thigh skin, acute hemorrhage, II degree shock, and uncompensated lower extremity ischemia throughout 24 hours. The MESS score of the injured extremity was 8 indicating that an amputation would have been considered. Nevertheless, we choose the organ preservation solution with the revascularization of the injured limb segment. A multi-stage treatment was carried out including stabilization of bone fragments, primary reconstruction of the popliteal artery to restore the arterial blood flow in the injured extremity, reperfusion injury and myoglobinuria elimination, intensive kidney protection therapy, infection management, skin defects replacement, orthopedic surgery. As a result of the treatment, the injured limb was saved. The femur fracture healed allowing the patient to walk without assistance. Conclusion. The use of the programmed surgical treatment for severe mechanical injury of the lower extremity, an individual multi disciplinary approach, assessing the severity of systemic disorders, and timely use of extracorporeal detoxification made it possible to avoid amputation, perform organ preservation surgery, and create favorable conditions for restoring the supporting function of the lower extremity.

BACKGROUND. The lack of data on the epidemiology of presarcopenia/sarcopenia leads to an underestimation of the role of this condition in the structure of morbidity and mortality of haemodialysis patients in theRussian Federation. THE AIM: to study the epidemiological aspects of presarcopenia /sarcopenia in patients with chronic kidney disease stage 5d. PATIENTS AND METHODS. This study comprised 317 patients receiving programmed bicarbonate haemodialysis for 8.2 ± 5.1 years, among them 171 women and 146 men, the average age was 57.1 ± 11.3 years. The assessment of the presence of sarcopenia was performed using the method recommended by the European Working Group on Sarcopenia in Older People. RESULTS. The prevalence of presarcopenia was 0.7 % and sarcopenia 29.6 %. The incidence of skeletal muscle mass deficiency according to muscle mass index (IMM) was 30.3 %, 48.7 % showed a decrease in muscle strength according to dynamometry, and low performance of skeletal muscles according to 6 minute walk test was determined in 42.8 %. Sarcopenia patients were significantly characterized by lower body mass index, as well as higher body fat mass values. The duration of haemodialysis (χ2 = 22.376, p = 0.0001) and the patient's age (χ2 = 10.545 p = 0.014) were an independent risk factors for the development of sarcopenia. CONCLUSION. Sarcopenia is recorded more frequently in hemodialysis patients than presarcopenia. Its prevalence increases among patients of older age groups and with a hemodialysis duration of more than 5 years. The age and experience of dialysis make their independent contribution to the development of this syndrome.

Acquired myasthenia gravis is an autoimmune disease, based on the imbalance of humoral and cellular immunity, characterized by weakness and fatigue of skeletal muscles, and in some cases involvement of the heart muscle. In most cases, the object of the autoimmune destruction is peripheral nicotinic acetylcholine receptors of the postsynaptic membrane of the neuromuscular synapse. In myasthenia gravis there has been identified a number of other antigenic targets: muscle-specific tyrosine kinase, lowdensity lipoprotein receptor-related protein 4, titin, and ryanodine receptors skeletal muscles. Their specificity and pathogenetic role have been disclosed, but it is about 15-20% of seronegative forms that require further immunological research. Accurate diagnosis depends on the efficient detection of clinical forms of myasthenia gravis and full analysis of the autoimmune mechanisms underlying the disease.

Due to the fact that acquired myasthenia gravis is an autoimmune disease, so rational treatment of these patients includes the symptomatic therapy (acetylcholinesterase inhibitors, potassium supplements, potassiumsaving diuretics), short-term immunotherapy (intravenous immunoglobulin, methods of extracorporeal hemocorrection), longterm immunotherapy (glucocorticosteroids, cytotoxic agents, targeted therapies), thymectomy, as well as a number of new promising therapeutic agents. The choice of effective therapy depends on identifying the clinical forms of myasthenia gravis and a complete analysis of autoimmune mechanisms underlying the disease because of similar clinical forms of myasthenia gravis may respond to similar therapies.

To study the efficacy of remaxol addition in the treatment scheme of alcohol withdrawal syndrome.Eighty patients with alcohol dependence and physical symptoms of alcohol withdrawal syndrome were enrolled. All patients received basic therapy in accordance to the applicable standards of treatment. The patients were randomized to remaxol introduced intravenously 2 times a day (morning and afternoon) in dose of 400 ml for 7 days (n=40) and saline with 25%-magnesium sulfate (10 ml) and 4% potassium chloride (10 ml) (n=40).The effectiveness of the inclusion of remaxol was expressed in a more rapid relief of asthenic syndrome, reduction of phenomena such as tension, dysphoria, headache and impaired coordination of samples. Patients treated with remaxol demonstrated a trend towards a more rapid reduction of the affective (p=0.08) and behavioral components (p=0.09) of the syndrome of pathological craving for alcohol. Hepatoprotective and detoxification properties of the drug were confirmed by the significant decline in ALT and AST activity to the 20th day of treatment. Significant positive changes in lipid metabolism (HDL to the 7th day of treatment) and a normalizing effect on the processes of tissue respiration were shown as well. No adverse effects were noted.The data obtained allow to recommend the inclusion of remaxol in the complex treatment regimens of alcohol withdrawal syndrome to improve the treatment efficacy.Цель исследования - изучение эффективности включения ремаксола в схему комплексного лечения больных с алкогольным абстинентным синдромом. Материал и методы. Лечили 80 пациентов с алкогольной зависимостью и клиническими признаками алкогольного абстинентного синдрома в стационарных условиях. Все пациенты получали базисную терапию в соответствии с применяемыми стандартами лечения; 40 больным (основная группа) был назначен ремаксол внутривенно капельно 2 раза в день (утром и днем) по 400 мл в течение 7 дней, в контрольной группе (40 человек) использовался физиологический раствор с 25% сульфатом магния (10 мл) и 4% хлоридом калия (10 мл). Результаты. Эффективность включения ремаксола в комплексную терапию состояла в более быстром купировании астенического синдрома, редукции таких явлений, как напряженность, дисфория, головная боль и нарушение координаторных проб. У пациентов, получавших ремаксол, выявлена тенденция к более быстрой редукции аффективного (р=0,08) и поведенческого (р=0,09) компонентов синдрома патологического влечения к алкоголю. Гепатопротективные и детоксикационные свойства препарата нашли подтверждение в достоверно значимом снижении показателей АЛТ и АСТ к 20-му дню лечения, кроме того выявлены достоверная положительная динамика показателей липидного обмена к 7-му дню лечения и нормализующее действие на процессы тканевого дыхания. Нежелательных явлений, связанных с исследуемым препаратом, отмечено не было. Заключение. Полученные данные позволяют рекомендовать включение ремаксола в комплексную терапию алкогольного абстинентного синдрома с целью повышения эффективности лечения.