[The characteristics of left ventricular myocardial remodeling in patients with chronic renal disease, and the effects of spironolactone therapy].

The work reflects modern concepts of the pathogenesis of myocardial and vascular remodelling in a chronic renal disease. Types of changes in left ventricular geometry and the condition of the diastolic function in patients at pre-dialysis stage of a chronic renal disease and patients on program hemodialysis. Dynamic changes in left ventricular parameters under the influence of therapy with spironolactone, an aldosterone receptor blocker, are described. The use of spironolactone in a dose of 25 mg per day is shown to regress myocardial hypertrophy in anuric patients on hemodialysis.

[Epidemiology and risk factors of chronic renal diseases: a regional level of the problem].

AIM: Assessment of chronic renal disease (CRD) prevalence and morbidity rate and approaches to early CRD in one of the regions of the RF (Tyva Republic). MATERIAL AND METHODS: A population study in the Tyva Republic performed from 01.07.2003 to 30.06.2004 included patients with glomerular filtration rate (GFR) < 30 ml/min, nephrosclerosis signs at autopsy, terminal GFR < 30 ml/min, on replacement renal therapy (RRT). CRD prevalence and morbidity were estimated (stage IV-V). Examination of 374 Tyva citizens was made for estimation of early CRD and risk factors of developing CRD (the sectional study). The participants of the sectional study were examined clinically and biochemically with measurement of albuminuria, calculation of urine albumin/creatinine (ACR) and study of some molecular-genetic characteristics. RESULTS: Prevalence of CRD stage IV-V in Tyva population was 493 cases per million, prevalence of RRT--126 cases per million. Elevated ACR was found in 4.7% of healthy subjects and 15.9% of hypertensive subjects. Initial lowering of GFR occurred in some healthy subjects and in 1 of 12 hypertensive patients. Significant predictors of albuminuria were serum albumin concentration (p < 0.00001), GFR (p < 0.0002), a male sex (p < 0.004), diabetes mellitus (DM) (p = 0.0057) and left ventricular myocardial mass index (p = 0.0253). GFR depended significantly on age (p < 0.000001), male sex (p < 0.000001), uric acid concentration in the serum (p < 0.000001), presence of DM (p = 0.000019), ACR (p = 0.0059), diastolic pressure (p = 0.0347), triglyceridemia (p = 0.0369). Citizens of Tyva had more frequently than citizens of other regions of Russia IlI-genotype of angiotensin 1-converting enzyme (ACE) (p < 0.0001), T-allele of methylentetrahydrofolatereductase (p < 0.0001), E3-allele of gene of apoprotein E (p < 0.0001). Prevalence of aa, ab, bb genotypes of eNO-synthetase was 82.3%, 15% and 2.7% in the group of Tyva examinees vs 62, 31 and 7% in European Russians (p < 0.01). CONCLUSION: Prevalence of both early and advanced stages of CRD among population of Tyva Republic is rather high. CRD morbidity may depend, besides conventional risk factors, some genetic specific features. Screening studies require continuation for early detection of CRD and timely planning of therapeutic and preventive measures.

[Effect of protein load on kidney functions in patients with chronic glomerulonephritis]. / Vliianie belkovoi nagruzki na funktsional'noe sostoianie pochek u bol'nykh khronicheskim glomerulonefritom.

AIM: To study changes in renal function in response to protein loads in patients with chronic glomerulonephritis (CGN) who have normal renal function and initial uremia. MATERIAL AND METHODS: 63 CGN patients were divided into two groups: 40 patients of group 1 (17 males, 23 females, age 16-53 years, plasma creatinine-Pcr < 0.132 mmol/l); 23 patients of group 2 (10 males, 13 females, age 18-57 years, Pcr > 0.132 mmol/l). Renal functional reserve (RFR) was assessed with oral soa isolate SUPRO 760 test (protein Techn. Int., USA), 1.0 g of protein per 1 kg of ideal body mass. By three 2-h clearance periods measurements were made of RFR, absolute and fractional excretion, concentration indices and clearances of creatinine, urea, electrolytes, osmolality. All the parameters were referred to the standard body surface. RESULTS: RFR was intact in 14 patients of group 1 and 10 patients of group 2. In CGN without uremia with intact RFR, maximal Pcr corresponded to the highest values of minute diuresis and sharp increase of urea excretion, osmotically active substances. In CGN patients with uremia and intact RFR, development of hyperfiltration was accompanied with a significant rise in Pcr, minute diuresis, absolute excretion of urea and osmotically active substances. The rise in the latter two was much less active in CGN if RFR was absent. Multiple stepwise regression analysis showed that RFR intactness depends primarily on baseline values of absolute excretion of urea and osmotically active substances. CONCLUSION: A reverse relationship exists between absolute excretion of urea, osmotically active substances and the degree of SKF in response to protein load in CGN patients both in intact nitrogen-excreting function and uremia. It is suggested that urea may be involved in regulation of intraglomerular hemodynamics by means of effect on tubular-glomerular feedback mechanism.

[Effects of different variants of low-protein diet on progression of chronic renal failure and indices of nutritional status in predialysis stage]. / Vliianie razlichnykh rezhimov malobelkovoi diety na progressirovanie khronicheskoi pochechnoi nedostatochnosti u pokazateli sostoianiia pitaniia na dodializnom étape.

AIM: To investigate effects of different variants of low-protein diet (LPD) (standard and with soy bean protein isolates) on inhibition of chronic renal failure (CRF) progression and prevention of protein-energy insufficiency in predialysis patients. MATERIALS AND METHODS: 150 patients with CRF were divided into three groups 50 patients each. Group 1 patients were given combined LPD with addition of soy bean isolate (0.4 g of protein per 1 kg of recommended body mass a day with standard diet and 0.2 g/kg with protein isolate SUPRO 760). Group 2 patients were given standard LPD without additives (0.6 g/kg a day). Patients of group 3 received free diet. All the patients were normally supplied with energy (at least 30-35 kcal/day). In the course of 26 months, clinical, laboratory, anthropometric, expected and functional parameters were measured each 4 months. RESULTS: Progression of CRF inhibited in patients with restricted protein provision. LPD had no negative effect on laboratory indices. Soy bean isolate LPD was more effective in inhibition of the disease progression than the standard one. CONCLUSION: LPD can be used for a long time for inhibition of the progression of CRF provided energy requirements are met. LPD with food additives (soya bean protein isolates) hold perspective for correction of metabolic disorders.

[The effect of urea on the course of experimental uremia in rats with a subtotal nephrectomy]. / Vliianie mocheviny na techenie éksperimental'noi uremii u krys s subtotal'noi nefréktomiei.

The important role of increasing plasma urea levels in renal failure progression was shown in Wistar rats with experimental uremia induced by subtotal nephrectomy. Renal structural lesions and dysfunction were the same as in rats fed a high-protein diet and in those on a low-protein diet supplemented with urea. The changes were much less in the control group of rats fed a low-protein diet alone. The findings suggest that high blood urea concentrations appear to be a cause of intraglomerular hemodynamic disturbances following renal failure progression.

[The reaction of the kidneys and acid-base and osmotic homeostasis to moderate physical exertion in patients with chronic pyelonephritis in the pre-azotemia period]. / Reaktsiia pochek, kislotno-osnovnogo i osmoticheskogo gomeostaza na umerennoe fizicheskoe napriazhenie u bol'nykh khronicheskim pielonefritom v doazotemicheskom periode.

Bicycle ergometry (BE) up to submaximal heart rate provoked moderate metabolic acidosis in 52 patients with chronic pyelonephritis (CP) in preuremic stage. Similar changes in acid-base balance following BE were noted in 14 patients with chronic glomerulonephritis (CGN). BE in CP promoted the reduction in diuresis and fraction water excretion, elevation of creatinine concentration in the urine and its concentration index in the absence of alterations in sodium and osmotic homeostasis. In CGN BE induced similar changes but an insignificant decrease in diuresis and a significant rise in serum sodium concentrations, osmolality of the urine, osmotic concentration index, absolute reabsorption of osmotically free water, fall in excreted sodium fraction. It is suggested that the above differences in the response to exercise test in CP and CGN may relate to tubulointerstitial nature of CP.

[The problems in optimizing the delivery of general therapeutic care at the regional level during the transition to compulsory medical insurance]. / Problemy optimizatsii okazaniia obshcheterapevticheskoi pomoshchi na territorial'nom urovne v usloviiakh perekhoda k obiazatel'nomu meditsinskomu strakhovaniiu.

The authors hold that perfection of local therapeutic service in present-day situation when insurance principles are introduced in medical care may be achieved through design of medico-economic standards of guaranteed minimum of medical aid for each citizen of Russian Federation. This approach allows accurate estimation of required personnel and equipment. The standards should not replace the principle of individual approach to each case.

[The effect of the angiotensin-converting enzyme inhibitor enalapril on the rates of progression of chronic kidney failure in patients with different degrees of functional kidney disorders]. / Vliianie ingibitora angiotenzinprevrashchaiushchego fermenta énalaprila na tempy progressirovaniia khronicheskoi pochechnoi nedostatochnosti u bol'nykh narusheniiami funktsional'nogo sostoianiia pochek razlichnoi stepeni.

By a reciprocal of creatininemia the rate of chronic renal failure progression (CRF) was assessed in 14 patients with nephropathy on enalapril treatment. The day dose ranged from 2.5 to 15 mg. In patients with serum creatinin levels from 0.24 to 0.41 mmol/l (group 1) enalapril significantly inhibited CRF progression, as it did in group 2 (serum creatinin levels from 0.47 to 0.68 mmol/l) but 1 patient. In patients with creatinin levels over 0.71 mmol/l, the influence of enalapril on CRF progression rate was insignificant. All the patients exhibited stabilization of arterial hypertension. Proteinuria diminished in groups 1 and 2, while creatinin clearance decreased in groups 1 and 3. It is inferred that enalapril control of renal function in nephropathy patients is efficient only in early CRF.

[An evaluation of the relationships between the ionic and osmotic secretory capacities of the kidneys and interstitial medullary edema in patients with chronic glomerulonephritis]. / Otsenka sviazei mezhdu iono- i osmovydelitel'noi sposobnost'iu pochek i otekom interstitsiia mozgovogo veshchestva u bol'nykh khronicheskim glomerulonefritom.

Ion- and osmoregulatory capacity of the kidneys under induced water diuresis have been investigated in 100 patients with chronic glomerulonephritis (CGN) with reference to CGN clinical and morphological variants. An independent morphologist conducted a blind assessment of the results obtained at semiquantitative light morphometry of the renal medullary interstitial edema. According to an original formula, the morphometric index of the renal medullary edema was transformed into the index of the effective medullary edema (EME). The greatest EME occurred in CGN patients with nephrotic syndrome (NS). These patients and those with CGN and isolated urinary syndrome displayed inverse nonlinear relationship between EME and clearance of endogenic creatinine (Ccr), p < 0.05. In patients with CGN and NS, CGN and secondary arterial hypertension, membranoproliferative glomerulonephritis (MPGN), membranous glomerulonephritis (MGN) with NS advancing EME demonstrated association with decreased sodium or chlorine clearance. In groups with MPGN, MGN with NS a nonlinear relationship existed between EME and urea clearance. The findings suggest an important role of renal medullary edema in promoting disorders of renal filtration and ion-secretion capacity in CGN.

[The cytochemical characteristics of the epithelium of the proximal nephron and of the endothelium of the peritubular capillaries and kidney functional status in chronic glomerulonephritis patients]. / Tsitokhimicheskaia kharakteristika épiteliia proksimal'nogo otdela nefrona, éndoteliia peritubuliarnykh kapilliarov i funktsional'noe sostoianie pochek u bol'nykh khronicheskim glomerulonefritom.

To assess the role of metabolic shifts in pathogenesis of excretory renal dysfunction arising in chronic glomerulonephritis (CGN), two groups of patients were considered. Fourteen patients of group 1 had CGN in a preazotemia stage, thirteen patients of group 2 died of CGN-induced uremia. Cortical nephrobiopsies obtained intravitally (group 1) and renal tissue specimens obtained at autopsies during postmortal hours 0-2 (group 2) were investigated. Apical epithelium of proximal canaliculi in group 1 showed higher levels of acid phosphatase (AP), though much lower of succinate dehydrogenase (SDH) and lactate dehydrogenase (LDH) compared to group 2. In basal proximal nephrothelium of group 1 the activity of LDH and AP was inhibited against these values in group 2. The activity of NADPN2-dehydrogenase, SDH and AP in group 1 surpassed that in group 2 in endothelium of renal cortex peritubular capillaries. These structures LDH and AP proved more active in group 1. The authors observed a series of significant multidirectional correlations between the activity of the enzymes studied and renal excretion. The growing activity of NADN2-dehydrogenase and AP was associated with diminution of electrolyte and water excretion, while enhancing LDH activity exhibited the opposite effect. It is concluded that progression of cortical disorders in the kidneys of CGN patients entails serious metabolic derangement reflected by imbalance in aerobic and anaerobic metabolism. These biochemical shifts result in ambiguous functional sequelae and may contribute both to renal retention of fluid, electrolytes and their excretion. The latter is likely a compensatory mechanism involved in maintenance of water-salt homeostasis in relevant patients.

[The role of disorders in the tubular transport of water and osmotically active substances in the progression of chronic kidney failure]. / Rol' narushenii kanal'tsevogo transporta vody i osmoticheski aktivnykh veshchestv v progressirovanii khronicheskoi pochechnoi nedostatochnosti.

Lithium clearance served the criterion for measuring proximal and distal tubular transport of water, sodium and osmotically active substances (OAS) in 41 patients with chronic renal failure (CRF) of various degree. Distal reabsorption of water and sodium occurs early in CRF. In moderate disease the authors observed a drastic rise in distal excreted fraction of OAS which surpassed that of sodium threefold. Proximal fractional excretion of water acquired defects in advanced CRF only. In the range of creatinine clearance 30-65 ml/min an inverse relationship appeared between the clearance and the ratio of urea of OAS concentrations to chlorine concentrations. Distal fractional OAS excretion correlated with relevant parameters directly. It is suggested that a decline in relative chlorine ions content in the tubular fluid at the site of the thick spot entails hypoactivity of the tubular-glomerular feedback mechanisms resultant in hypertension and hyperfiltration in the intact nephrons which start to perish because of overloading.

[The transport of sodium, water and active osmotic substances in different parts of the nephron of patients with chronic glomerulonephritis and hypertension]. / Transport natriia, vody i osmoticheskikh aktivnykh veshchestv v razlichnykh uchastkakh nefrona u bol'nykh khronicheskim glomerulonefritom i gipertonicheskoi bolezn'iu.

The lithium test was conducted to evaluate transport of water, sodium and osmotic active substances in 46 chronic glomerulonephritis (CG) patients. Sixteen CG patients entered group 1. All of them had secondary hypertension (SH). Twelve CG patients with SH symptoms of moderate reduction of endogenic creatinine clearance were assigned to group 2. Twelve patients of group 3 had CG and isolated urinary syndrome. Group 4 consisted of 6 patients with essential hypertension. As shown by the test, association of SH and CG is not an essential factor for renal transport of sodium, water and electrolytes. Some shifts in the transport in group 2 are attributed to reduced number of functioning nephrons. The tendency to enhanced lithium clearance was registered in group 4. This may reflect an increased supply of sodium, water and osmotic active substances to the uriniferous tubules.

[The morphofunctional parallels in arterial hypertension in patients with chronic glomerulonephritis]. / Morfofunktsional'nye paralleli pri arterial'noi gipertonii u bol'nykh khronicheskim glomerulonefritom.

A study was made of the structural rearrangement of renal tissues in intravital nephrobiopsy specimens and of the functioning of the renin-angiotensin-aldosterone system and kallikrein-synthetic function in patients with mesangioproliferative (MSPGN) and membranous proliferative glomerulonephritis (MPGN). The morphological changes were revealed. The patients with associated MSPGN and secondary hypertension (SH) mostly demonstrated emptying and hyalinosis of arteries, whereas those with associated MPGN and SH manifested for the most part the derangement of the tubulointerstitial structures. In patients with MPGN, the levels of total renin (TR) and inactive renin (IR) were significantly higher than in those suffering from MSPGN. This can be regarded as risk factor of earlier development of SH. In MPGN patients, the content of TR and IR as well as that of active renin (AR) did not depend on the clinical pattern of chronic glomerulonephritis. As compared to MSPGN patients with isolated urinary syndrome, those with associated MSPGN and SH had a higher AR level, which agreed well with systolic and mean arterial pressure. Apparently, the latter one is implicated in the mechanism of SH in MSPGN. In associated MPGN and SH, kallikreinuria was found to be lowest, which may be the consequence of tubulointerstitial lesions. Discoordination of the renin-angiotensin and kallikrein systems is likely to be one of the causes of earlier formation and severe course of SH in the morphological pattern under consideration.

[The morphofunctional parallels in arterial hypertension in patients with chronic glomerulonephritis]. / Morfofunktsional'nye paralleli pri arterial'noi gipertensii u bol'nykh khronicheskim glomerulonefritom.

The restructure of renal tissue in intravital nephric biopsy specimens, renin-angiotensin-aldosterone together with kallikrein synthetic functions were studied and compared in patients with mesangioproliferative and membranoproliferative glomerulonephritis (MsPGN and MPGN). The characteristics of the morphological changes were defined. In MsPGN with secondary hypertension (SH), nephronic wasting and hyalinosis of arteries were mostly detectable whereas MPGN with SH was primarily marked by the derangement of the tubulointerstitial structures. In MPGN, the levels of total and inactive renin (TR and IR) were significantly higher than in MsPGN. This can be regarded as risk factor of early development of SH. The content of TR and IR and in addition that of active renin (AR) in MRGN did not depend on the clinical form of chronic glomerulonephritis. As compared to MsPGN with an isolated urinary syndrome, in MsPGN with SH, AR was prevalent, while its level correlated well with systolic and the mean arterial pressure. AR may be implicated in the mechanism of SH in MsPGN. In MPGN with SH, kallikreinuria was found to be extremely low, which may be consequent to tubulointerstitial injuries. The discoordination of the renin-angiotensin and kallikrein system may be one of the causes of earlier formation and the grave course of SH in the morphological pattern under consideration.

[The participation of the kallikrein-kinin system in edema formation in glomerulonephritis]. / Uchastie kallikrein-kininovoi sistemy v formirovanii otekov pri glomerulonefrite.

Involvement of the kallikrein-kinin system in the pathogenesis of renal edemas may be mediated by increase of vascular permeability, proteinuria, diuresis and natriuresis. Proceeding from these points, in 27 patients with morphologically proved chronic glomerulonephritis and the nephrotic syndrome, the serum kallikrein activity and its 24-hour urinary excretion level were measured. According to their edematous syndrome severity, all the patients were divided into 2 groups: 1) 19 patients with moderate edemas; 2) 8 patients with severe ones. During the follow-up period, there were no essential changes in patients' body weights, and no significant differences between the groups in clearances and excreted fractions of sodium, potassium, chlorine, osmotically active substances, and in serum albumin and cholesterol levels, 24-hour protein losses and blood pressure. As compared to the healthy (n-20) in all the patients a substantial and statistically significant increase in kallikrein activity was revealed in serum and urine. Kallikreinemia and kallikreinuria were significantly higher in Group 2 than those in Group 1. In the total group of examinees a significant direct relationship was established between the urinary kallikrein activity and summary sodium and potassium excretion as well as between the serum kallikrein activity and chlorine clearance. A direct correlation between the serum kallikrein activity and proteinuria was also found. Thus, a role of the kallikrein-kinin system in development of glomerulonephritic edemas concurrent with the nephrotic syndrome is hetero-directional.(ABSTRACT TRUNCATED AT 250 WORDS)

[THe role of the kallikrein-kinin system in the origin of proteinuria in glomerulonephritis]. / Rol' kallikrein-kininovoi sistemy v proiskhozhdenii proteinurii pri glomerulonefrite.

The kallikrein-kinin system of the blood serum (prekallikrein and kallikrein) was studied in 68 patients with chronic glomerulonephritis with the purpose of determining the significance of this system in the origin of proteinuria, protein content in the morning portion of urine and 24-hour portion. Linear correlation analysis revealed a direct relation of the levels of kallikrein and prekallikrein in the blood serum the morning and 24 losses of protein in patients suffering of glomerulonephritis with an isolated urinary syndrome (18 patients), nephrotic (27 patients) and glomerulonephritis with arterial hypertension.

[The role of the kallikrein-kinin and renin-angiotensin-aldosterone systems in the development of hypertension in glomerulonephritis]. / Rol' kallikrein-kininovoi i renin-angiotenzin-al'dosteronovoi sistem v formirovanii gipertenzii pri glomerulonefrite.

A total of 74 patients with various clinicomorphological variants of glomerulonephritis (GN) were examined. Only a high activity of the enzyme kinase-1 that destroys kinins and the kallikrein inhibitors alpha 1-antitrypsin, alpha 2-macroglobulin is a contribution of the kallikrein-kinin system made to the general antihypertensive "armoury" of the body, as shown by the study. The correlation between the kallikrein activity and the active renin/total renin ratio predetermines that kallikrein may participate in endogenous plasma renin activation in GN patients. In this case, the vasoconstrictive effect of renin may limit the antihypertensive action of kallikrein and kinins by a feedback mechanism.

[Water and sodium transport in different parts of the nephron in glomerulonephritis patients with nephrotic syndrome]. / Transport vody i natriia v razlichnykh uchastkakh nefrona u bol'nykh glomerulonefritom s nefroticheskim sindromom.

Altogether 34 patients with the nephrotic syndrome (NS) of chronic glomerulonephritis (CGN) were studied for lithium clearance (CLi). Eleven patients with edemas were enrolled in group I, 18 subjects without pronounced edemas, in group II. Out of them 7 patients suffered from membrane proliferative glomerulonephritis (group III), 7, from mesangioproliferative glomerulonephritis (group IV), 4 subjects had focal glomerulosclerosis (group V); chronic renal failure (CRF), stages IIb-IIIa, was diagnosed in 7 patients enlisted in group VI. The control group consisted of 11 virtually healthy persons. On the CLi basis the authors identified the proximal excretory water fraction (EFpH2O), the distal excretory fraction of the water (EFdH2O) and the distal excretory fraction of sodium (EFdNa). The controls demonstrated the mean values of the parameters considered: 16.18 +/- 1.56 ml/min; 19.88 +/- 1.63; 7.19 +/- 1.16 and 4.38 +/- 7.76 per cent, respectively. Decreased CLi was revealed in groups I and II. Versus the controls patients enrolled in group II demonstrated a significant decrease of EFpH2O (11.91 +/- 2.22 per cent; p less than 0.05) and an increase of EFdH2O (16.81 +/- 3.26 per cent; p less than 0.05). A great individual variance of the parameters considered (from 1.32 to 55.63 per cent and from 2.33 to 118 per cent, respectively) hindered to reveal the difference between group I and the controls.(ABSTRACT TRUNCATED AT 250 WORDS)