LEADING ARTICLE
REVIEWS AND LECTURES
ORIGINAL ARTICLES. CLINICAL INVESTIGATIONS
THE AIM of the investigation was to study the level of plasma homocysteine in patients at different stages of chronic renal disease (CRD). PATIENTS AND METHODS. The level of plasma homocysteine (HCy) was determined by the method of highly effective liquid chromatography in 219 patients with different stages of CRD, 125 of the patients were at the predialysis stage and 94 patients were treated by chronic bicarbonate hemodialysis. RESULTS. The incidence of hyperhomocysteinemia was high as early as at the initial stages of CRD and was increasing along with decreasing GFR and reached the maximum in the group of dialysis patients. An inverse dependence was revealed between the GFR and the plasma HCy level in the group of patients not given dialysis treatment. CONCLUSION. An increased level of plasma homocysteine is noted beginning from the early stages of CRD and reaches the maximally high values and incidence in patients treated by hemodialysis.
THE AIM of the investigation was to determine the types of attitude to illness prevailing in patients on hemodialysis (HD) and the variables associated with the attitude of these patients to illness. PATIENTS AND METHODS. Examination of 218 patients treated by chronic HD allowed to detect their subjective attitude to the illness and to study the treatment with the questionnaire «Type of attitude to illness». The following parameters were determined in all the patients: quality of life, coping strategies, levels of depression, asthenia and anxiety as well as the clinical signs in order to establish the variables associated with the attitude of these patients to their illness. RESULTS. The HD patients mostly had ergopathic («getting away from disease to work»), sensitive (with hypersensitivity) and harmonious types of attitude to illness. In 62% of the patients types of the attitude of the adaptive block prevail that speaks of adaptive reaction to the illness and treatment. The types of attitude to illness was shown to be connected with the parameters of life quality, character of emotional sphere, labor employment, level of education, strategies of overcoming the problems, duration of the kidney disease and HD treatment, specificity of beginning HD, blood serum albumin level, change of the body mass for the last 6 months. CONCLUSION. HD patients mainly have the ergopathic, sensitive and harmonious types of attitude to the illness, the paranoiac and dystrophic types are rare that speaks of good adaptive potency of these patients. The attitude to illness is closely connected with the quality of life of the patient, the emotional state, employment, education level, coping strategies and following medical recommendations.
THE AIM of the work was to compare different techniques of determining the residual renal function for the establishment of the most reliable criterion of selection of patients for beginning the substitution renal therapy (SRT). PATIENTS AND METHODS. A retrospective comparative analysis of three means of determining the residual renal function was made in 208 patients with the terminal stage of chronic renal failure in three dialysis centers of St.Petersburg at the period from 1986 through 2004. RESULTS. It was found that the values of creatinine clearance determined by two methods (with the Rehberg test and by the formula CockcroftGault) differed from the values of the glomerular filtration rate (GFR) calculated by MDRD formula. The index of survival of dialysis patients was used in order to determine the prospective value of the calculation methods. Mathematically it was confirmed that among the methods of determining the excretory function of the kidneys the GFR indices calculated by the MDRD formula were the only significant predictor of lethality independent of stratification. CONCLUSION. It was convincingly shown that the determination of the residual renal function values calculated by GFR using the modified MDRD formula allows the development of common criteria for correct selection of patients for the beginning of dialysis. The values calculated by MDRD formula are the only ones from the investigated indices of the residual function of the kidneys at the start of SRT influencing the survival of dialysis patients.
THE AIM of the investigation was to assess the influence of representatives of different subclasses of calcium channels on clinicolaboratory indices of hypertensive patients having chronic glomerulonephritis with anephrotic syndrome. PATIENTS AND METHODS. Under observation there were 112 hypertensive chronic glomerulonephritis patients with anephrotic syndrome. The patients were divided into 5 groups on the basis of the specially developed criteria. The patients of each group were of the same age at the beginning of the disease, the same morphological variant of the disease and the same gender. The first group included 25 patients (20 men and 5 women) given prolonged nifedipin (30120 mg/day in two takings); the second group included 26 patients (20 men and 6 women) given verapamil (120480 mg/day in 3 takings), 8 of them were given a retard form of the medicine (120240 mg/day 12 times a day); the third group consisted of 24 patients (19 men and 5 women) given amlodipin (510 mg/ day); the fourth group consisted of 19 patients (10 men and 9 women) given diltiazem (90360 mg/day); the fifth group consisted of 18 patients (10 men and 8 women) given lacidipin (48 mg in one taking). The investigation included the initial period, randomization of the patients into groups of observation and the main period (the beginning of taking the drugs and working through the doses and number of taking). Before the beginning of taking the calcium channel blocker, in 3 weeks after the beginning of treatment and in 3 years after the beginning of observation the patients were investigated for diurnal proteinuria, fibronectinuria. Calculations of glomerular filtration rate, index of glomerular permeability and degree of albuminuria were made. Protein fractions of blood serum, content of total cholesterol and triglycerides were studied. Nephrobiopsy was made as well as monitoring of arterial pressure. RESULTS. Lacidipin, diltiazem and verapamil were found to have renoprotective properties such as the ability to reduce diurnal proteinuria, the degree of albuminuria and glomerular filtration index. In contrast, amlodipin and nifedipin increased the diurnal proteinuria, but significantly reduced the concentration of total cholesterol and triglyceride of blood serum. So they can be recommended for the treatment of secondary hyperlipidemia in hypertensive patients with chronic glomerulonephritis. CONCLUSION. Renoprotective properties of lacidipin, diltiazem and verapamil allow them to be considered as hypotensive medicines of «the first line» in hypertensive patients with chronic glomerulonephritis.
THE AIM of the investigation was to sum up the personal experiences with treatment of patients with moderate and severe forms of hemorrhagic fever with renal syndrome (HFRS). PATIENTS AND METHODS. In the period from 1973 till 2003 under observation there were 355 patients with the medium severity of the disease and sever forms of HFRS. Before 1979 efferent methods of treatment were used in 48% of the patients (50 from 105). Later the optimization of hemodialysis (HD) regimens allowed this method to be used in 128 out of 180 patients (69.5%). Finally, the estimation was made of the results of treatment of 50 patients by HD only, by plasmapheresis (PF) only (n=50) and in 15 patients with polyorganic failure treated by a combination of HD and PF. RESULTS. Lethality in the years from 1973 till 1979 made up 16.1%, from 1980 till 1990 6.1%. The further decrease of lethality (since 1989) was associated with using PF. Eventually, a clear algorithm was developed for treatment of patients with severe forms of HFRS. Immediately after admission the patient underwent massive PF (the volume of plasma exfusion not less than 1000 ml). If the patient failed to reestablish diuresis, HD with anticoagulation with fractionated heparins should be started by the indications with continuing PF. CONCLUSION. Treatment of patients with moderate and severe forms of HFRS should be started with massive PF. If the patient has an oligoanuric stage of acute renal failure and indications for HD, the procedure should be accompanied with anticoagulation with fractionated heparins. Using autocryoplasma in repeated plasmaphereses and in the stage of polyuria considerably lessened the cost of treatment.
THE AIM of the work was to assess the structure and indices of lethality and approximate characteristics of mortality of nephrologic patients in St.Petersburg during the years 19932003. PATIENTS AND METHODS. The records of 110287 postmortal examinations were analyzed. Their results were assessed by at least three independent experts. The criterion of selection was the presence of a nephrologic pathology. Later on 16075 records were selected where the nephrologic pathology was combined with chronic renal failure (CRF). With the population of St.Petersburg taken into account (the data of the passport offices and the census of population, the technology and order of pathoanatomical examination, total number of the dead), the number of the dead with nephrologic pathology combined with chronic renal failure was counted per 1 million of population in a month depending on the direct cause of death according to the International Classification of Disease (ICD) 9 and ICD10. Mortality from each cause was estimated for each month of observation that later allowed to make an analysis of the corresponding mean (X) and standard deviations (±SD) as the main sign of variability of the temporal row and standard errors of the mean (m) as a measure of visualization of this variability. RESULTS. At the present time chronic renal failure is not the main cause of death in nephrological patients with CRF. The main part of nephrological patients die from cardiovascular diseases, not having lived till CRF. CONCLUSION. Diseases of the cardio vascular system were the main cause of lethal outcomes in nephrological patients at the period from 1993 till 2003. Diabetes mellitus is not the main cause of death in CRF patients given specialized nephrological and endocrinological care in St.Petersburg.
THE AIM of the investigation was to study effects of furosemid on the indices of oxidant and antioxidant statuses of the kidney under conditions of acute experimental ischemia. MATERIAL AND METHODS. Ischemia of the kidney was caused in rats by ligation of the left renal artery for 4 hours. Furosemid (20 mg/kg) was injected intraperitoneally 1,3 and 10 hours before ischemia. Total oxidant activity and thiobarbiturate sensitive products of lipid peroxidation were determined. The antioxidant status was estimated by changes of the indices of total antioxidant activity (TAA) and by activity of antioxidant enzymes catalase, superoxide dismutase (SOD) and glutathione peroxidase (GPO). RESULTS. Experiments in vivo have shown that after injection of furosemide the oxidant status indices did not practically differ from those in control animals against the background of four hour long ischemia. In contrast, the antioxidant activity indices were substantially changed under the influence of the diuretic. If in control experiments the dramatic growth of the radical level in ischemia activated the antioxidant system in the kidneys, the preliminary injection of furosemide prevented activation of TAA in ischemic kidneys. The maximal effect was noted after injection of the diuretic 10 hours before ischemia. The catalase activity correlated with the changes of TAA activity. Changes of activity of SOD and GPO were less pronounced. CONCLUSION. In direct experiments with experimental acute ischemia of the kidney it was shown that furosemid increased the resistance of the renal tissue to hypoxia thus preventing activation of the antioxidant system. It is fairly possible that the ability of the diuretic to suppress the intensity of processes of free radical oxidation is a good contribution to prevent an ischemic lesion of the kidney.
THE AIM of the investigation was to study morphohistochemical alterations of the kidney tubule epithelium of experimental animals after acute poisoning with methyl alcohol. MATERIAL AND METHODS. A lethal dose of methanol was introduced through a probe into the stomach of 30 white rats of both sexes. Renal tissue sections were stained with hematoxylineosin and picrofuchsin after VanGieson. Activity of succinate dehydrogenase, lactate dehydrogenase, NADH 2dehydrogenase, acid phosphatase and alkaline phosphatase was detected on sections frozen in liquid nitrogen. RESULTS. Introduction of methanol was found to result not only in severe structural alterations of the organ, but also in a complex impairment of intracellular metabolism of the proximal and distal tubule nephrothelium and functional state of the microcellular bed which can be taken for early signs of toxic effects of methanol and development of acute renal failure. CONCLUSION. Methanol has a direct nephrotoxic effect resulting in structural metabolic impairments which can be a basis for the development of nephropathy with symptoms of acute renal failure.
THE AIM of the investigation was to determine possibilities of erythropoietin correction of oxidative doxorubicin induced stress in rat kidneys. MATREIAL AND METHODS. The investigation was fulfilled in white rats. One group of animals (n=7) was given intraperitoneal injections of doxorubicin, in the other group doxorubicin was injected intraperitoneally simultaneously with intravenous injection of erythropoietin (n=7). The animals including a control group (n=7) were killed in 24 hours. The content of the reduced glutathione (GSH), activity of glutathioneStransferase (GST), activity of cytoplasm NADPH:quinone oxidoreductase 1 (HXO 1), activity of glutathione reductase (GR), the content of protein carbonyl groups were investigated in homogenate of the kidney tissue. RESULTS. The introduction of doxorubicin resulted in lower level of GSH (0,061±0.017 versus 0.089±0.011 mkmol/mg of tissue in the control group, p<0.05) and activity of GR (62.10±8.04 versus 85.80±7.18 nmol/min/mg of protein in the control group, p<0.05) in the kidney homogenate. The introduction of erythropoietin prevented attenuation of GSH and activity of GR and led to increased activity of HXO 1 in the kidney homogenate. CONCLUSION. No difference was noted between the content of protein carbonyl groups in the kidney homogenate in the investigated groups of animals.
THE AIM of the investigation was to study effects of rifampicin on the functional state of white rat kidneys under conditions of a single and continuous infusion of the drug. MATERIAL AND METHODS. Aqueous solution of rifampicin was administered into the stomach of mature male rats as a single dose (75 mg/kg of body mass) and during 7 days (30 mg/kg of body mass).The kidney function was determined under conditions of 5% water load in 24 hours after discontinuation of giving the drug. RESULTS. It was found that rifampicin caused a mildly reduced glomerular filtration rate and increased excretion of endogenous nitrates and nitrites independent of the method of introduction. At the same time, a reliably increased rate of excretion of protein by the kidneys was noted but in the group of rats given the drug in a dose 75 mg/kg of b.m. CONCLUSION. It was shown that a single or continuous doses of rifampicin resulted in reliably changed functional state of the kidneys a decreased glomerular filtration rate and increased renal excretion of endogenous nitrates and nitrites. The kidneys were found to respond to the amount of the given drug that might be due to the power of the mechanisms of biotransformation of rifampicin in organism and its renal clearance.
JOURNAL IN THE JOURNAL. ACTUAL PROBLEMS OF UROLOGY
THE AIM of the investigation was to analyze longterm results of adjuvant intravesical immunotherapy with BCG vaccine «Imuron» in subtotal dosage 100 mg and chemotherapy with thiophosphamide in the regimen of a single early postoperative injection in the dose 20 mg in patients with superficial transitional cell carcinomas of the urinary bladder who had transurenal resection (TUR) and to estimate the contribution of adjuvant therapy to prognosis of the disease. PATIENTS AND METHODS. The materials of the primary examination and fiveyear dispensary followup of 173 patients on whom TUR had been performed for superficial transitional cell carcinoma of the urinary bladder were studied retrospectively. In a month after TUR 42 patients received a course of instillation of BCG vaccine «Imuron» by 100 mg once a week during 6 weeks, 18 patients were given a single intravesical instillation of 20 mg of thiotepa immediately after TUR. The signs associated with recurrences and progression of carcinoma and with the survival of the patients at the postoperative period were analyzed. RESULTS. A course of immunotherapy with BCG vaccine after TUR resulted in three times less incidence of recurrent carcinoma (p0.1). The multiple regression analysis has shown (R2 =0.15; p=0.016) that the leading factors allowing prognosis of the patient’s survival independent of other indices are the depth of invasion and degree of differentiation of the primary tumor. CONCLUSION. The intravesical course therapy with BCG vaccine «Imuron» in dosage 100 mg once a week during 6 weeks and early postoperative single intravesical instillation of 20 mg thiotepa were shown to be effective means to decrease the incidence of postoperative recurrences of superficial transitional cell carcinomas of the urinary bladder. The depth of invasion and degree of differentiation of the primary tumor are the leading factors in prognozing the clinical course of the disease.
THE AIM of the investigation was to reveal clinicomorphological predictors of distant metastases after radical retropubic prostatectomy in prostate cancer patients and to create a prognostic mathematical model of the appearance of this complication. РATIENTS AND METHODS. An analysis of incidence of distant metastases was made in 150 patients with localized forms of prostate cancer after radical retropubic prostatectomy with special reference to clinicomorphological factors of risk of this complication. The maximal period of the dynamic followup was 5 years. RESULTS. It was found that the leading risk factors of the appearance of distant metastases proved to be clinical and morphological factors: ingrowth of the tumor into the seminal vesicles by the data of transrectal ultrasonography (F=20.94; p<0.00001) and the degree of tumor differentiation in transrectal biopsy of the prostate (F=26.51; p<0.00001), as well as extracapsular spread of the tumor by the data of a morphological examination of the operation material (F=21.84; p<0.000001). The linear discriminant analysis was used to make a mathematical model which allowed prognosis of the appearance of distant metastases of prostate cancer in 96.6% of cases (l=0.54; p<0.000001). CONCLUSION. Prediction of the appearance of distant metastases of prostate cancer after radical prostatectomy should be made with regard for clinicomorphological factors of risk of this complication.
THE AIM of the investigation was to increase reliability of the assessment of the presence and degree of infravesical obstruction (IVO) in patients with benign hyperplasia of the prostate (BHP) on the basis of common methods of urologic examination. PATIENTS AND METHODS. Eighty BHP patients, mean age 58.2±2.1 years, were examined. The examination included the assessment of complains by the IPSS score, ultrasonic investigation with determination of the prostate size and amount of the residual urine and urodynamic investigation including uroflowmetry and miction cystometry («pressureflow» investigation). RESUILTS. The assessment of BHP symptoms, the prostate size, quantity of residual urine and maximal volume rate of urination can not always speak of peculiarities of the disturbances of functions of the lower urinary pathways in BHP patients, the presence and degree of IVO included. So, a formula was developed for a complex estimation of clinical indices for more exact and reliable determination of the IVO presence: D1 =0.818× Smax +0.0006×Smin+0.215× Qmax 0.478× Qaver , where D1 is the discriminant function; Smax is the maximal linear size of the prostate; Qmax is the maximal volume rate of urination and Qaver is the average rate of urination.In D1 ≥2.85 IVO can be determined, in D1<2.85 IVO is more likely to be absent. CONCLUSION. The developed formula allows a more exact and reliable diagnosis of IVO in BHP patients as compared to the isolated assessment of clinical indices.
PRACTICAL NOTES
DISCUSSION AND INFORMATION
Proceedings of session of the nephrologic section of the St.Petersburg society of therapeutists named after S.P.Botkin.
Robert Vardgesovich Babakhanyan (to his 65th birthday).
Nataliya Nikolaevna Smirnova.
ISSN 2541-9439 (Online)
