[Diagnostic and treatment difficulties in kidney damage in the patient with generalized sarcoidosis during COVID-19. Case report].

The presented clinical observation reflects the difficulties of differential diagnosis of progressive kidney damage in a patient with sarcoidosis who has undergone a new coronavirus infection. The differential circle included interstitial nephritis as an exacerbation of the underlying disease, acute drug-induced kidney injury, acute glomerulonephritis. Nephrobiopsy confirmed the diagnosis of acute sarcoid tubulointerstitial nephritis with acute tubular necrosis. Timely administration of corticosteroids led to the control of the sarcoidosis process, restoration of kidney function.

[Low serum Klotho level as a predictor of calcification of the heart and blood vessels in patients with CKD stages 2-5D].

Cardiovascular calcification (CVC) makes a significant contribution to the manifestation of cardiovascular complications in patients with chronic kidney disease. Early CVC markers are currently being actively studied to optimize cardio-renoprotective strategies. We performed a prospective comparative analysis of the following factors: FGF-23, a-Klotho, sclecrostin, phosphate, parathyroid hormone, the estimated glomerular filtration rate (eGFR), central systolic pressure as an independent determinant of CVC. MATERIALS AND METHODS: The study included 131 patients with chronic kidney disease 25D st. Serum levels of FGF-23, Klotho, and sclerostin were evaluated using the ELISA method. Vascular augmentation (stiffness) indices, central arterial pressure (using the SphygmoCor device), calcification of heart valves and the degree of aortic calcification (aortic radiography) were also investigated. The observation period was 2 years. RESULTS: According to the Spearman correlation analysis, the percent of calcification increase and the change in Klotho level are most related. According to ROC analysis, a decrease in serum levels of Klotho by 50 units or more is a significant predictor of an increase in aortic calcification of 50% or more with a sensitivity of 86% and a specificity of 77%. Using logistic regression analysis, it was found that a serum Klotho level 632 pg/L predicts an eGFR below a median level of 48 ml/min/1.73 m2 with a sensitivity of 85.5% and a specificity of 78.5%. Wherein OR 17.477 (CI 95% 8.04637.962; p0.001). CONCLUSION: The factor most associated with CVC is Klotho. Decreased serum level of Klotho is a predictor of aortic calcification. In addition, the initial serum level of Klotho is a predictor of eGFR after 2 years.

[Visceral leishmaniasis: a challenging diagnosis in internal medicine].

Leishmaniasis is a vector-born parasitic disease characterized by predominant cutaneous or visceral involvement with fever, hepatosplenomegaly and anemia. Leishmaniasis has relatively high prevalence in tropical and subtropical areas. Several sporadic and mostly imported cases are detected in Russian Federation. Nevertheless, some local incidents are noted in southern areas (Crimea, Dagestan). Lack of epidemiological alertness hampers confirmation of diagnosis and may lead to incorrect treatment. The article summarizes current state of knowledge in epidemiology, diagnostic approach and treatment of leishmaniasis. Particular clinical case is discussed.

Pneumoconiosises: modern view.

The article is devoted to the actual problem - dust diseases of the lungs. The peculiarities of occurrence and course of pulmonary lesions that have a significant place in the overall structure of occupational morbidity are considered. Modern approaches to treatment, diagnostics and prevention issues in pneumoconiosis are discussed.

Autoimmune liver disease (primary biliary cholangitis/autoimmune hepatitis-overlap) associated with sarcoidosis (clinical cases and literature review).

Clinical features of overlap autoimmune hepatitis/primary biliary cholangitis and morphological-proved sarcoid lesions (lungs, lymph nodes, skin) were performed. Data of long-term clinical observation presented in comparison with the results of laboratory datas, instrumental and morphological studies of liver tissue, lungs, skin. The modern aspects of pathogenesis of association autoimmune and granulomatous diseases arediscussed on the example of clinical cases of combination of cholestatic variants of autoimmune hepatitis and generalized sarcoidosis. Keywords: sarcoidosis, autoimmune hepatitis, primary biliary cholangitis, primary biliary cholangitis-autoimmune hepatitis-overlap, extrahepatic manifestations.

[Low protein diet with essential amino acids ketoanalogues combination can affect serum FGF-23 and Klotho levels in chronic kidney disease 3b-4 stages patients: randomized pilot study].

Protein restriction diet (PRD) with ketoanalagues of essential amino acids (KA) combination can improve of chronic kidney disease (CKD) course while, the precise mechanisms of PRD + KAA action in CKD are not known yet. We have conducted a prospective, randomized, controlled study of PRD and KAA patient's group in compare with PRD without KAA group in regarding to serum Klotho and FGF-23 levels in patients with CKD. MATERIALS AND METHODS: The study included 79 CKD 3b-4 stages patients, non - diabetic etiology, used PRD (0.6 g/kg/day). The patients were randomized in two groups: 42 patients, received PRD + KAA (Group 1) and 37 patients continued the PRD without KAA (Group 2). Serum FGF-23 (Human FGF-23 ELISA kit with antibodies to native FGF-23 molecule, Merk Millipore MILLENZFGF-23-32K), Klotho (Human soluble Klotho with antiKlotho monoclonal antibodies, IBL-Takara 27998-96Well) levels, as well as instrumental examination: bioimpedance analysis [assess of muscle body mass (MBM), fat body mass (FBM), body mass index (BMI) and others]; sphygmography [assess of augmentation (stiffness) indices (AI), central (aortal) blood pressure (CBP) by «Sphygmacor¼ device]; as well as echocardiography [assess of cardiac (valvular) calcification score (CCS) and left ventricular myocardium mass index (LVMMI)], were studded in addition to conventional examination. RESULTS AND DISCUSSION: To the end of 14th month of the study the PRD group reached a body mass index (BMI) decrease (p=0.046), including MBM in men (p=0.027) and woman (p=0.044). In addition, higher FGF-23 (p=0.029), and lower Klotho (p=0.037) serum levels were revealed in the PRD group compared to the PRD+KAA group as well as the increase in AI (p=0.034), CCS (p=0.048), and LVMMI (p=0.023). CONCLUSION: Use of PRD + KAA provides adequate nutrition status and more efficient correction of FGF-23 and Klotho imbalance in CKD progression that may contribute to alleviation of both cardiovascular calcification and cardiac remodeling in CKD. Importantly, a prolonged PRD use without supplementation of KAA may lead to malnutrition signs.

[Serum troponin-I as a marker of fibroblast growth factor-23 (FGF-23) cardiotoxic effect, in patients with chronic kidney disease].

AIM: It has been established that an increased fibroblast growth factor (FGF-23) serum levels significantly contribute to the heart and blood vessels remodeling in patients with chronic kidney disease (CKD). But the precise mechanisms of the FGF-23 cardiac effect are currently being actively studied. At the same time, it is believed that the cardiac effects of FGF-23 may be due to the increasing deficit of Klotho protein as CKD progresses. In parallel with these changes, a number of studies indicate the persistence of the detectable troponins serum levels in CKD patients, even in the absence of clear clinical manifestations of cardiovascular diseases (CVD). The aim of the study was to confirm / exclude the existence of a causal relationship between elevated FGF-23, reduced Klotho and elevated troponin-I (as the most specific troponin in CKD). MATERIALS AND METHODS: The study included 130 CKD stages 1-5D patients without clinically pronounced symptoms of СVD (Coronary artery disease, CCS class 2-4, Chronic heart failure, NYHA 24, myocarditis, pericarditis, arrhythmias), as well as the severe arterial hypertension (BP >160/90 mm Hg), according to the laboratory and instrumental methods of examination. The selected group of patients was studied: serum levels of FGF-23 (Human FGF-23 ELISA kit), Klotho (Human soluble Klotho with antiklotho monoclonal antibodies), troponin-I (high - sensitive assay), and also data from instrumental examination methods: electrocardiography (ECG), echocardiography (left ventricular myocardial mass index (LVMI), cardiac (valvular) calcification score (CCS) using a semi - quantitative point scale), sphygmagraphy (augmentation (stiffness) indices of vessels (AI), pulse wave velocity (PWV), central (aortic) blood pressure (CBP), blood supply of subendocardium (BSE) - using "Shygmacor" device (Australia)). RESULTS AND DISCUSSION: The changes in serum levels of FGF-23, Klotho and troponin-I (Tr-I) depended on the stage of CKD. The following correlations were identified: FGF-23 and: Tr-I (r=0.601; p.

[Chronic kidney disease in the context of toxic effects the working chemical factors (literature review)].

The article analyzes the publications devoted to the problem of professional renal lesions caused by chemical factors. Classification, prevalence, peculiarities of the clinical picture, diagnosis of professional renal lesions caused by chemical factors of the production environment are reviewed. The frequency of professional renal lesions remains underestimated due to low manifestation of symptoms and the influence of environmental factors, which require further investigation of this issue.

[Effect of right ventricular myocardial contractility on the response to cardiac resynchronization therapy].

AIM: To determine the effect of right ventricular myocardial contractility on the response to cardiac resynchronization therapy (CRT). MATERIALS AND METHODS: The study included 80 patients (49 men, mean age 54±10.5) diagnosed with dilated cardiomyopathy, complete left bundle branch block, and the QRS complex width 146 to 240 ms (183±32 ms). Heart failure was NYHA FC III, ejection fraction (EF) - 30.1±3.8 %, 6­min walk test - 290.5±64.3 m, and end-diastolic volume (EDV) - 220.7±50.9 ml. 35 patients had permanent atrial fibrillation. All patients received implantable devices for CRT; complete artificial atrioventricular block was formed in patients with atrial fibrillation. LV and right ventricular (RV) contractile function was studied in all patients before and at 12 months of the implantation using equilibrium radionuclide tomoventriculography. RESULTS: At 12 months, 69 (86.25 %) patients were clinical responders to CRT and 11 (13.75 %) patients did not respond to the treatment. The responders showed positive clinical dynamics; LV EF increased from 30.1±3.8 to 42.8±4.8 % (p≤0.001), LV EDV decreased from 220.7±50.9 to 197.9±47.8 ml (p≤0.005). In non-responders, LV EF increased from 30.1±3.8 to 33.8±3.8 % (p≤0.001) and LV EDV increased from 220.7±50.9 to 227.8±27.8 ml (p≤0.001). All patients were retrospectively divided into two groups: Group 1, CRT responders and Group 2, non-responders. A study using radionuclide methods showed that in Group 1 patients, maximum RV filling velocity increased from 1.8±0.36 to 2.17±0.67 (p≤0.001) and the mean velocity of RV filling for one third of diastole increased from 1±0.28 to 1.32±0.45 (p≤0.001). In Group 2, these parameters were significantly worse by 30 and 60 %, respectively. CONCLUSIONS: Cardiac resynchronization therapy is more effective in preserved contractility of the right heart, and higher values of maximum RV filling velocity for one third of diastole may serve a prognostic criterium for a beneficial response to CRT.

Variety of lung involvement in autoimmune liver diseases.

The primary autoimmune liver diseases conventionally include primary biliary cholangitis, primary sclerosing cholangitis and autoimmune hepatitis. Despite of primary autoimmune affection of different parts of the hepatobiliary system, in the recent decades, a lot of data has emerged indicating the presence of extrahepatic manifestations of these diseases, in particular, lung lesions, such as nodular and interstitial changes with possible progression and development of fibrosis and respiratory failure. In case of lungs disease, both pulmonary parenchyma and lung vessels, pleura, and intrathoracic lymph nodes can be involved. The most sensitive and specific procedure to assess the extent of the lung lesions and their evolution is high-resolution computed tomography. Due to the possibility of long-term asymptomatic course of the pulmonary disease with development of irreversible changes in patients with autoimmune liver diseases, it seems reasonable to conduct screening studies aimed at early detection and treatment of lung lesions in this population.

Arterial hypertension at the workplace: risk factors and the population value.

The article presents data of domestic and foreign authors on the relationship between occupational factors and arterial hypertension. The role  of latent arterial hypertension, its frequency in the population, the lesion of the target organs and the prognosis in comparison with normotensive individuals, arterial hypertension of the "white coat" and stable arterial hypertension have been analyzed. Arterial hypertension in the workplace is a form of latent arterial hypertension. The authors review the influence of harmful production factors (physical, chemical), as well as psychosocial stress on the risk of developing arterial hypertension.The risk of developing hypertension in specified groups of workers has been analyzed separately. The place of production-related diseases in modern occupational pathology in the Russian Federation. A wider implementation of measures aimed at early diagnosis and prevention of arterial hypertension in workers is proposed.

Bilateral thalamic stroke in patient with patent foramen ovale and hereditary thrombophilia.

Patent foramen ovale and hereditary thrombophilia are both known risk factors for ischemic stroke. Artery of Percheron is a rare anatomical variant in which vast areas of the midbrain and thalamus have a single source of blood supply. This case report presents a 45-years old female patient with bilateral thalamic stroke due to Percheron artery occlusion, with a combination of hereditary thrombophilia and patent foramen ovale as the risk factors. Modern approaches to the diagnosis and secondary prevention of this pathology are also discussed herein.

Clinical significance of the determination of surfactant proteins A and D in assessing the activity of lung sarcoidosis.

AIM: To study the clinical significance of SP-A, SP-D in assessing the activity of idiopathic pulmonary fibrosis and sarcoidosis. We examined 81 patients with morphologically confirmed diagnoses of idiopathic pulmonary fibrosis (ILF) and sarcoidosis, a control group of 20 healthy individuals. The MSCT of the thoracic organs of the chest was performed, the diffusivity of the lungs was examined, oxygen saturation was determined. In the serum, the surfactant proteins SP-A and SP-D were determined by the enzyme-linked immunosorbent assay. RESULTS: A significant increase in SP-A and SP-D (p<0.05) was observed in patients compared with patients in the control group, a direct correlation was found with signs of activity: SP-A with alveolitis (p<0.05), SP- D with progressive fibrosis (p<0.05), inverse correlation of surfactant proteins with respiratory function indices (p<0.05). CONCLUSION: Serological parameters of SP-A and SP-D reflect the activity of alveolitis and the progression of pulmonary fibrosis in patients with ILF and sarcoidosis.

[Thrombectomy and plication of veins as a method of preventing pulmonary artery thromboembolism at a multidisciplinary surgical hospital].

The authors assessed efficacy and safety of the operation of plication of deep veins of lower extremities, pelvic veins, and the inferior vena cava as a method of preventing fatal pulmonary artery thromboembolism. A total of 48 patients were operated on. Of these, 23 patients belonged to traumatological-and-orthopaedical cohort, 3 to general surgical cohort, 4 to gynaecological, and 18 to vascular cohort (isolated deep vein thrombosis). The length of the floating head of the thrombus varied from 2 to 10 cm. The presence of a floating thrombus in traumatological, surgical and gynaecological patients, regardless of the length of the floating part was an absolute indication for thrombectomy and venous plication. Vascular patients were operated on in accordance with the National Guidelines (with the length of the thrombus floating portion of not less than 4 cm). In all cases, surgical management envisaged direct and indirect thrombectomy. Plication was always performed above the level of venotomy. It was shown that thrombectomy combined with plication of major veins is a reliable and safe method of prophylaxis, being in some cases the only possible method of preventing fatal pulmonary artery thromboembolism. The operation of plication makes it possible not to cancel a scheduled surgical intervention in patients with a detected floating thrombus of major veins. The operation of thrombectomy and plication above the level of the floating head of the thrombus may be considered an operation of choice in the conditions where there is no possibility to use endovascular methods of treatment (implantation of a cava filter, endovascular catheter thrombectomy), as well as in pregnant women. Restoration of the venous lumen occurs at safe terms spontaneously, not requiring repeat surgical intervention. Simultaneous plication of the vein does not complicate the course of the postoperative period of the main surgical intervention. Thrombectomy and plication do not lead to the development of severe chronic venous insufficiency.

[Occupational factors and a risk of cardiovascular diseases]. / Professional'nye faktory i risk razvitiia serdechno-sosudistykh zabolevanii.

The paper gives Russian and foreign authors' data on a relationship between occupational factors and cardiovascular diseases. It considers the impact of psychosocial stress on the risk of hypertension, coronary heart disease, and cardiovascular events in representatives of different professional groups.

[Decreased Serum Levels of Klotho Protein in Chronic Kidney Disease Patients: Clinical Imortance].

Objective: To determine the role of serum Klotho (s-Klotho) protein levels changes in patients with different stages of chronic kidney disease (CKD). Methods: The study involved 130 patients with CKD stages 1­5D (mean age ­ 41±6.7 years). Serum levels of parathyroid hormone (PTH), calcium, phosphorus and s-Klotho protein (ELISA method) at baseline and after 1 year of follow-up were examined in all the patients so as the blood pressure (BP), including central (aortic), pulse wave velocity ­ with the help of «Sphygmоcor¼ (Australia), echocardiography, radiography of the abdominal aorta in a lateral projection were also performed. Results: Ehen comparing the s-Klotho levels in patients with different CKD stages, it was found that the level change associated with the reduction of glomerular filtration rate (GFR) ahead of phosphorus and PTH increase in serum, stared at 3A CKD, whereas hyperphosphatemia and PTH increase started at 4­5 CKD stages. According to ROC analysis, decreasing of s-Klotho levels below 387 pg/ml was indicated a calcification risk of abdominal aorta increased with an 80% sensitivity and 75% specificity. In addition, a strong negative relationship of low s-Klotho levels and heart remodeling was found. When comparing the patients with hypertension who were receiving antihypertensive monotherapy, the highest serum levels of Klotho protein were observed in those of them whose target blood pressure level was achieved primarily through Angiotensin II Receptors Blockers (ARB), compared to those who was administered another drug group (p<0.01) or has not reached the target blood pressure level (p=0,008). Conclusion: The change of serum Klotho levels (decrease) in CKD progression is associated with the degree (increase) of cardiovascular calcification and remodeling (the development of left ventricular hypertrophy, and cardiomyopathy) and it can be seen as an early independent marker of the cardiovascular system lesions in CKD. Our preliminary data of the effect of blood pressure correction on s-Klotho levels may indicate the possibility of drug maintaining serum Klotho levels and it requires further research.

[The recovering of breeding achievements of Populus × leningradensis bogd. and Populus × newensis bogd. Based on microsatellite analysis].

The genotyping of 75 trees from poplar plantations in St. Petersburg and Leningrad oblast was conducted with microsatellite markers to identify the elite clonal varieties developed by P.L. Bogdanov in the period of 1938­1965. The information about the varieties was lost. The authentic herbarium specimens of poplar clonal varieties preserved at the St. Petersburg State Forest Technical University were used as reference genotypes. According to the results of DNA fingerprinting, we identified the clonal plantations of Populus × newesis Bogd. and Populus × leningradensis Bogd. from the Kartashevskii forest district and the arboretum of the St. Petersburg State Forest Technical University. The identified elite poplar hybrids have a higher frost resistant and a higher growth rate. They are recommended for plantation cultivation in the northwest of Russia.

[Role of the morphogenetic proteins FGF-23 and Klotho and the glycoprotein sclerostin in the assessment of the risk of cardiovascular diseases and the prognosis of chronic kidney disease].

UNLABELLED: AIM. To analyze changes in the serum concentrations of the morphogenetic proteins fibroblast growth factor 23 (FGF-23) and Klotho, as well as sclerostin, an osteocyte-secreted glycoprotein, in relation to the degree of hypertension, left ventricular (LV) hypertrophy, and arterial stiffness in patients with chronic kidney disease (CKD) at its different stages. SUBJECTS AND METHODS: Sixty-five patients (33 men and 32 women) aged 20-65 years, including 25 with chronic glomerulonephritis, 15 with tubulointerstitial nephritis, and 25 with hypertensive nephrosclerosis, were examined. A control group consisted of 15 healthy volunteers matched to the study group patients for age and gender. Serum FGF-23 concentrations and blood pressure (BP) were measured in the all subjects. Patients with BPs > 140/80 mm Hg underwent echocardiography, followed by determination of LV mass (LVM) and calculation of LVM index. Vascular circulation, pulse wave velocity, cardiac and vascular calcifications, and vascular functional properties were estimated. RESULTS: There was a strong direct Correlation between the serum concentration of FGF-23 and the stage of CKD and an inverse correlation between the levels of Klotho and sclerostin and the stage of CKD. As the glomerular filtration rate became lower, the concentration of FGF-23 increased and that of Klotho and sclerostin decreased just in Stage III CKD while hyperphosphatemia and elevated parathyroid hormone levels were noted in Stages IV-V CKD. As CKD progressed, the serum concentrations of Klotho and sclerostin were inversely correlated with the levels of phosphorus and parathyroid hormone. The degree of blood pressure elevation correlated positively with serum FGF-23 concentrations and inversely with Klotho levels. There was no significant correlation of the level of sclerostin with the degree of BP increase. The direct correlation between higher FGF-23 level and higher VLM is most pronounced in hypertensive patients. There was a strong direct relationship between FGF-23 and Klotho levels and a strong inverse relationship between sclerostin levels and pulse wave velocity. Lower Klotho concentrations were associated with the detection rate of calcifications in the heart valves and large arteries (the abdominal aorta). The reduced serum levels of Klotho and sclerostin were also correlated with concentric LV remodeling. CONCLUSION: It was demonstrated that there was a clear link between increased serum FGF-23 and decreased Klotho concentration as CKD progressed, and that between arterial stiffness and calcification and myocardial remodelling regardless of traditional risk factors. More experimental and clinical studies are required to clarify the role of sclerostin in CKD.

[Clinical value of surfactant protein D as a biomarker of pulmonary fibrosis in patients with scleroderma systematica in relation to the presence of gastroesophageal reflux].

AIM: To study the role of serum surfactant protein D (SP-D) as a biomarker of lung injury in scleroderma systematica (SDS) in relation to the presence of gastroesophageal reflux (GER). SUBJECTS AND METHODS: Fifty-six patients (mean age 46±14 years) with diffuse and circumscribed SDS were examined and underwent pulmonary functional tests, X-ray and, if lung injury was present, high-resolution computed tomography of the lung, echocardiography, gastroduodenoscopy, and barium X-ray of the esophagus; an enzyme-linked immunosorbent assay was used to determine serum SP-D levels. RESULTS: SP-D concentrations significantly correlate with the presence of lung injury in SDS and are significantly higher in the presence of pulmonary fibrosis and the signs of frosted glass and honeycomb lung patterns. SP-D levels were higher in the patients with lung injury and SDS in the group of those with pulmonary fibrosis and GER than in the group of pulmonary fibrosis patients without the latter. CONCLUSION: Serum SP-D may be considered in a number of biomarkers for the severity of lung injury in SDS, including GER-associated lung injury.

[Practical aspects of treatment in patients with chronic cerebral ischemia and hypertension in general somatic practice].

The official statistics of the Ministry of Health of the Russian Federation show that the past 10 years have been marked by an increase in the number of patients with chronic cerebral circulatory disorders (CCCD), accounting for at least 700 per 100,000 population. Hypertension is the most studied etiological factor of CCCD. However, its role is often perceived uniquely as the major mechanism for destabilization of the arterial vascular bed. The detailed study of the pathogenesis of impairments in the cerebral vascular bed and neurons will be able to predict the further course of the disease and to choose adequate therapy.