[New and potential biomarkers of acute kidney damage.]

The review presents literature data on the efficacy of new and potential biomarkers for the early diagnosis of acute renal damage. Early non-invasive and cost-effective kidney damage biomarkers are vital for determining the tactics, effectiveness and prognosis of treatment. Their use will not only reduce morbidity and mortality, but also reduce health care costs.

[Scintigraphic assessment of alterations in cardiopulmonary haemodynamics and renal functional activity in patients with endured coronary artery bypass grafting].

OBJECTIVE: By means of scintigraphic methods to assess alterations in cardiopulmonary haemodynamics and renal functional activity in patients with coronary artery disease (CAD) after endured coronary artery bypass grafting (CABG) performed in conditions of extracorporeal circulation (EC) and on the functioning heart. MATERIAL AND METHODS: We examined a total of 40 patients presenting with CAD (mean age 54.90±1.12 years) after endured CABG. All patients were subdivided into 2 groups: Group One consisting of 20 patients subjected to CABG performed on the beating heart with the use of myocardial "stabilizer" "Acrobat" (Study Group) and Group Two also comprising 20 patients but undergoing surgery with the use of extracorporeal circulation (Comparison Group). All patients included into the study were subjected to radiocardiopulmonography with (99m)Tc-pertechnetate and dynamic radionuclide renoscintigraphy with (99m)Tc-DTPA before and 6-7 days after operative treatment. RESULTS: In the early postoperative period after CABG, the patients of the both groups were found to have a significant increase in the minute volume, cardiac index, and circulation efficiency coefficient, accompanied by a significant decrease in the period of half-emptying of the left ventricle, thus suggesting improvement of LV contractility. Improved pulmonary microcirculation resulting from operative treatment in the compared groups of patients was confirmed by significantly shortened time of the indicator's passing through pulmonary vessels at the expense of both arterial (TAM) and venous (TVM) components. At the same time, a decrease in these parameters in the Study Group patients was more pronounced as compared with the Comparison Group patients. Thus, the means of the difference between the pre- and postoperative values of TAM and TVM in the Study Group amounted to 1.78 ± .40 s and 1.78 ± 0.32 s, and in the Comparison Group to 0.95 ± 0.22 s and 0.98 ± 0.16 s, respectively (p=0.029 and p=0.031 for TAM and TVM, respectively). The Comparison Group patients after CABG were found to have a significant decrease in the mean values of the total glomerular filtration rate (GFR) in combination with decelerated clearance of the indicator from blood. 30% of patients under the effect of nonpulsating blood flow developed relatively pronounced renal dysfunction (a decrease in the total GFR and/or GRF of one of the kidneys by 15% and more as compared with the initial level). Besides, these patients also demonstrated significant changes in the half-clearance of the radiopharmaceutical from the renal parenchyma and the index of cortical retention of the indicator on the both sides. Unlike the Comparison Group, in patients without EC the average values of the majority of parameters of renal filtration activity underwent no statistically significant alterations as compared with the baseline (prior to CABG) values. CONCLUSION: Coronary artery bypass grafting without cardiac arrest exerts less pronounced negative influence upon the state of the renal function as compared with the open-heart surgery with extracorporeal circulation, which may partially be conditioned by statistically more significant positive dynamics of microcirculation in the system of pulmonary circulation under the effect of myocardial revascularization with the use of the myocardial stabilizer "off-pump".

[Scintigraphic evaluation of impairments in cardiopulmonary hemodynamics and renal functional activity in patients with coronary heart disease and circulatory failure].

OBJECTIVE: To evaluate the relationship between impairments in cardiopulmonary hemodynamics and renal functional activity in patients with circulatory failure, by applying radionuclide studies. MATERIAL AND METHODS: Sixty-nine patients with coronary heart disease (mean age 53.23 +/- 0.87 years) with the development of NYHA functional classes II-III chronic HF were examined. To calculate cardiopulmonary hemodynamic parameters, all the patients underwent 99mTc pertechnetate radiocardiopulmonography. Their renal functional activity was assessed by dynamic radionuclide renal scintigraphy using 99mTc-DTPA. RESULTS: The examinees had most abnormal systemic and pulmonary hemodynamic parameters. Renal dysfunction was detected in 74% of the examinees and reflected by decreased glomerular filtration rates in one or both kidneys and/or a longer tracer elimination half-life from the renal parenchyma. Stepwise regression analysis established a strong inverse correlation between impaired pulmonary circulation, on the one hand, and reduced renal filtration, on the other, and a direct correlation of impairments in renal filtration and evacuation with both left and right ventricular contractility. CONCLUSION: Radionuclide studies are the methods of choice for diagnosis of the cardiorenal continuum.

[Effect of hypoxic preconditioning on the level of s-NGAL (lipocalin-2) in myocardial revascularization in the conditions of extracorporeal haemocirculation].

OBJECTIVE: To assess the effect of hypoxic preconditioning (HPC) on the level of s-NGAL (lipocalin-2) in myocardial revascularization under conditions of extracorporeal haemocirculation (EH). PATIENTS AND METHODS: We examined a total of 40 patients presenting with CAD (mean age 57.62±1.20 years) and subjected to coronary artery bypass grafting (CABG) under conditions of EH. All patients were subdivided into 2 groups. The study group comprised 20 patients who during CABG were subjected to HPC, and 20 patients made up the comparison group. Preconditioning was carried out in the mode of one cycle of 10-minute hypoxemia followed by a 5-minute period of reoxygenation. All patients were subjected to measuring the concentration of lipocalin in blood serum prior to CABG and 5 hours after the beginning of the operative intervention with the help of the test system Human Lipocain-2 NGAL, ELISA. RESULTS: Prior to operative treatment the average levels of lipocalin in blood serum of the patients of the compared groups significantly did not differ, with the inverse correlation between the levels of s-NGAL and the ejection fraction of the left ventricle (r=-0.37, p=0.02), as well as the glomerular filtration rate (according to the findings of radionuclide renoscintigraphy) and the level of lipocalin (r=-0.28, p=0.046). Five hours after the CABG, there was a statistically significant increase in the s-NGAL concentration as compared with the preoperative value both in the HPC group patients and the comparison group (from 70.65±10.72 to 127.58±22.59 ng/ml and from 65.01±8.64 to 171.65±20.10 ng/ml, respectively). There was a direct relationship between the duration of EH and the dynamics of the s-NGAL level in patients of the both groups. However, an increase in the NGAL concentration in the comparison group patients was considerably more manifested vs the study group patients (p=0.02). The median value of the difference between the pre- and postoperative values of the lipocalin level in Group I amounted to 56.94±19.76 ng/ml, being in Group II 106.64±18.94 ng/ml (p=0.004). CONCLUSION: Hypoxic preconditioning during myocardial revascularization under the conditions of extracorporeal haemocirculation prevents a critical elevation of the lipocalin-2 level, thus suggesting a decrease in the degree of the lesion of the renal parenchyma in cardiosurgical patients.

[Cardiorenal syndrome: currents views of relationships between renal and cardiovascular diseases].

Current concepts of the development and pathogenesis of cardiorenal syndrome are considered. Special emphasis is laid on the data concerning chronic renal diseases (CRD) as risk factors of cardiovascular disorders (CVD), pathophysiological features of CVD concomitant with CRD, and relationships between CRD and traditional risk factors of CVD. The development of renal dysfunction is regarded as a complication of the heart failure.

[Radionuclide renal scintigraphy in assessment of nephroprotective effect of hypoxic preconditioning for myocardial revascularization under artificial circulation].

OBJECTIVE: Using renal scintigraphy to assess the nephroprotective efficacy of hypoxic preconditioning (HP) during myocardial revascularization under the conditions of artificial circulation (AC). MATERIALS AND METHODS: We examined a total of forty-seven patients with CAD (mean age 52.81 +/- 1.40 years) who endured coronary artery bypass grafting (CABG) under AC. All patients were randomly divided into 2 groups:patients (n = 16) who during CABG underwent HP (study group) and those (n = 31) without renal protection (comparison group). HP was performed in the mode of one cycle of 10-minute hypoxemia followed by a 5-minute period of reoxygenation. Dynamic radionuclide renal scintigraphy with 99mTc-DTPA was carried out before and 6-7 days after surgical treatment with calculating the parameters of the filtrating and excreting renal function. RESULTS: The comparison-group patients after CABG were found to have negative dynamics of the parameters of the renal filtration activity. Thus there was a significant decrease in the mean values of total and individually for each kidney glomerular filtration rate (GFR) combined with deceleration of the blood clearance. Besides patients of this group showed a significant increase in the mean value of the half-period of excretion of the indicator from the pelvicalyceal system of the left kidney and the parenchyma of the both kidneys. The study group patients showed no alterations in the values of the filtration activity of the kidneys as compared with the baseline measures, with the exception of the GFR of the right kidney. Thus a decrease in the filtration function of either one kidney or both kidneys under the influence of non-pulsating blood flow was observed only in three (19%) patients and was not pronounced. Alterations in the indices reflecting the excretory renal function in the study group were also insignificant. CONCLUSION: Radionuclide renal scintigraphy makes it possible to objectively and with a high level of the informative value to determine the degree and pattern of the effect of open-heart surgery on renal functional activity. HPC exerts a nephroprotective effect action on the renal functional activity in patients with endured open-heart surgery in the conditions of assisted circulation.

[Radionuclide renoscintigraphy for the evaluation of nephroprotective action of acetylcysteine].

Radionuclide renoscintigraphy was used to evaluate efficiency of nephroprotection by N- acetylcholine in 36 patients subjected to coronaroangiography (CAG). The patients were randomly allocated to 2 groups, one undergoing CAG without nephroprotection, the other CAG in combination with N-acetylcholine nephroprotector. Dynamic radionuclide renoscintigraphy with 99m Tc-dtpa was performed before and 2-3 days after CAG; the results were used to estimate filtration and evacuation efficiency of the kidneys. Patients of group 1 showed negative dynamics of the renal function following CAG including decreased mean glomerular filtration rate and slowed down blood clearance. Mean half-time of 99mTc elimination from the pelvicalyceal system and parenchyma of the left kidney as well as its cortical retention index in bot kidneys increased. The filtration activity of the kidneys did not significantly change after CAF in patients of group 2; it was slightly impaired only in 5 (28%) of them. More patients suffered deterioration of 99mTc elimination but on the whole changes in the evacuation activity of both parenchyma and pelvicalyceal system were statistically insignificant. It is concluded that acetylcholine has nephroprotective action in patients subjected to radionuclide renoscintigraphy.

[Radionuclide methods of diagnosis in assessment of interrelationship between the function of the cardiovascular system and kidneys in patients with previously endured myocardial revascularization].

A steady increase in the number of patients diagnosed with chronic cardiac insufficiency determines the importance of studying in such patients the renal function for comprehen sive analysis of the incidence rate and mechanisms of the cardiorenal continuum. Radionuclide methods of diagnosis make it possible to obtain versatile information about the functional state of both the cardiovascular and urinary systems of the body. Radionuclide methods of study were used to prospectively assess the state of the cardiopulmonary haemodynamics and renal functional activity in patients with CAD after previously endured myocardial revascularization. The authors examined a total of twenty-nine patients suffering from coronary artery disease (CAD) (mean age 51.97 +/- 1.32 years) and having developed the NYHA functional class II-III circulatory insufficiency. All the patients were subjected to radiocardiopulmonography (RCPG) with 99mTc-pertechnetate and to dynamic radionuclide renoscintigraphy with 99mTc-DTPA before and after coronary artery bypass grafting (CABG). Fourteen patients were examined 13.0 +/- 0.4 months after surgical management. Prior to CABG, the parameters of the cardiopulmonary haemodynamics in the examined patients had considerable deviations from the normal values, resulting from a decrease in the pumping function of the heart. Prior to surgical management, 83% of the patients were found to have a various-degree decrease in the glomerular filtration rate. Restoration of the coronary blood flow at early terms following CABG along with improved perfusion in the examined patients was accompanied and followed by a positive change in a series of parameters of the cardiopulmonary haemodynamics. One year after direct myocardial revascularization, the patients with circulatory insufficiency were found to have certain relationship between the impairments of the central haemodynamics parameters and the development of renal function impairment. Hence, radionuclide methods of diagnosis should be used while monitoring the patients with circulatory insufficiency for the purposes of timely detection and correction of the cardiorenal syndrome.

[Renal radionuclide scintigraphy in the evaluation of radiopaque substances on renal function].

To evaluate the nephrotoxic effect of radiopaque substances (ROS) by renal radionuclide scintigraphy, 47 patients were examined before and after coronary ventriculography. Iohexol, iobitridole, and ioxythalamate were used as ROS in 15, 18, and 14 patients, respectively. The parameters of renal filtration and excretory function were calculated during study. Ioxythalamate was shown to have a less pronounced nephrotoxic effect.

[Cardiomyoplasty with autological mononuclear cells of the bone marrow in patients with acute myocardial infarction].

AIM: To study efficacy and safety of transplantation of bone marrow autologous mononuclear cells (BMAMC) in patients with acute myocardial infarction; to examine BMAMC distribution in the human body after intracoronary introduction. MATERIAL AND METHODS: The open controlled trial investigated 26 AMI patients (16 entered the study group and 10 were controls). Cell cardiomyoplasty with BMAMC was performed by intracoronary injection of the cells after stenting the coronary artery supplying blood to the infarction zone on AMI day 7-21. BMAMC were isolated by gradient centrifugation. Distribution of mononuclear cells was studied with radionuclear indication of the cells 99m-Tc-HMPAO. All the patients were examined with Tl-199 perfusion scintigraphy of the heart 2 weeks and 6 months after the treatment, echocardiography, 24-h ECG monitoring, 6-min walk test. RESULTS: All the patients were followed up for 6 months. Two patients (one in each group) developed recurrent myocardial infarction 3 months after the first. Radionuclide investigations revealed fixation of labelled mononuclear cells in the heart both in initial hours after the treatment and 24 hours after it. As shown by myocardial scintigraphy, intracoronary administration of the cells with short-term arterial occlusion was followed by much greater number of labeled cells. By follow-up month 6, in the study group, left ventricular ejection fraction increased more: 12.7 +/- 3.2% versus 10.4 +/- 2.5% in the control group (p = 0.09); moreover, a stable defect of myocardial perfusion reduced more (by 29 +/- 24% against 20 +/- 18%, respectively, p = 0.1). Malignant arrhythmia, complications during and after bone marrow aspiration, intracoronary administration of cell suspension were not registered. CONCLUSION: Intracoronary administration of BMAMC in AMI patients is safe and provides their transfer and fixation in the myocardium. BMAMC transplantation has a positive effect on recovery of perfusion and contractile function of left ventricular myocardium in AMI patients.

[An experience of the use of stenting for recurrence of myocardial ischemia after coronary artery bypass grafting].

Coronary artery stenting was carried out in 18 patients with angina recurrence 29.3+/-7.6 after coronary artery bypass grafting. Paired bicycle exercise tests, (199)Tl single photon emission tomography and graft angiography were used in evaluation of patients. Occlusions of 1 or 2 venous grafts were found in 38.9%, stenoses of both previously bypassed and native arteries in 27.8% of patients. Implantation of stents in grafts and/or native coronary arteries was associated with 2.7 fold decrease of angina frequency, 3 fold decrease of nitroglycerine consumption, 72.5% increase of exercise tolerance. The use of statins resulted in obvious lowering of total and low density lipoprotein cholesterol.

Scintigraphic evaluation of myocardial and cerebral blood flow in patients with a history of coronary artery bypass grafting.

This paper deals with a comparative scintigraphic evaluation of the changes that occur in coronary and cerebral circulation in patients with coronary artery disease (CAD) after coronary artery bypass grafting (CABG) under conditions of cardiopulmonary bypass (CPB) or beating heart. Twenty-nine CAD patients who underwent CPB were examined. Of these, 14 patients were operated on using CPB (the first group) and 15 patients on the beating heart using the myocardial "stabilizer" Octopus (the 2nd group). The patient groups matched in terms of the age, sex, the clinical and angiographic factors. Perfusion scintigraphy of the heart and brain by means of single-photon emission computed tomography (SPECT) and the neurologic evaluation were performed twice in all the patients: before and 2-4 weeks after CABG. The second group patients demonstrated a significant lowering of the mean magnitude of stable defects (SD) of myocardial perfusion. The lowering or disappearance of SD was observed in a greater percentage of cases versus the first group. All the patients were found to have areas of hypokinesis in the SD projection. Also, the second group showed a significant rise of the mean magnitude of left ventricle ejection fraction. Operations with CPB were associated with a 5% decrease of cerebral blood flow in the frontal and temporal lobes of the right hemisphere. No significant deterioration of brain perfusion was observed in patients (on the whole in the group) operated on without heart arrest. It is noteworthy that there was a significant improvement of the average group indicators of cerebral perfusion in the right occipital and posterior segments of the temporal lobes. The changes in cerebral perfusion were in agreement with the course of changes in the cognitive status. Thus, CABG on the resting heart in CAD patients favours a more remarkable restoration of perfusion and contractility of the hibernated myocardium versus revascularization performed under CPB and exerts, as a result, a beneficial effect on cerebral circulation and the neuropsychological status of the patients.

[Effect of trimetazidine on regressione of ischemic dysfunction of myocardium after coronary bypass surgery on beating heart]. / Vliianie miokardial'noi tsitoprotektsii trimetazidinom na regress ishemicheskoi disfunktsii miokarda u bol'nykh, perenesshikh operatsiiu koronarnogo shuntirovaniia na rabotaiushchem serdtse.

AIM: To study effect of trimetazidine on restoration of hibernating myocardium after myocardial revascularization on beating heart. MATERIAL: Patients with ischemic heart disease subjected to direct myocardial revascularization on beating heart: 25 patients received trimetazidine (60 mg/day) in pre and postoperative periods and 30 patients did not. METHODS: Echocardiography, veloergometry, 6 minute walk test, myocardial scintigraphy with Tl-199. RESULTS: Course (35 days) treatment with trimetazidine provided significant decrease of frequency and severity of episodes of angina, reduction of nitrate consumption, enhancement of tolerance to physical exercise, improvement of myocardial perfusion manifested as significant decrease of mean size of transient perfusion defects. CONCLUSION: These results demonstrate efficacy and expediency of trimetazidine use in therapy of reversible myocardial dysfunction in patients with ischemic heart disease subjected to direct myocardial revascularization.

Thallium-199 myocardial perfusion scintigraphy in the diagnosis of restenoses after balloon dilatation and stenting of the coronary arteries.

AIM: To evaluate the diagnostic importance of thallium-199 myocardial perfusion single-photon emission computed tomography (SPECT) in the recognition of coronary restenoses and stenoses de novo of varying sites after endovascular treatment of coronary artery disease (CAD). MATERIAL AND METHODS: Myocardial perfusion scintigraphy was used to examine forty-six patients presenting with CAD before, 2-3 weeks, 3-6 months and 1-2 years after balloon dilatation and/or stenting of the coronary arteries (CA). The presence, character and magnitude of perfusion defects were estimated. RESULTS: The coronary angioplasty resulted in a 76% decrease of the mean size of transient ischemic zones. The reversible defects of thallium accumulation coexisted after operation with incomplete myocardial revasculization in patients with hemodynamically significant multivessel lesions. In the long-term follow up (3-6 months and 1-2 years after endovascular treatment), aggravation of coronary insufficiency in patients with incomplete revascularization proceeded mainly due to an increase in the size of the areas marked by persistent disturbance of coronary microcirculation determined not only by acute necrotic myocardial infarction but also by transformation of transient ischemic zones to the new stable perfusion defects. As compared to the early times, the patients with verified restenoses and stenoses de novo showed in the later period (3-6 months after coronary angioplasty) a significant increase in the mean size of the transient ischemic zones, exceeding the preoperative level. In six of the eleven patients, the appearance of the new stable defects was marked after 1-2 years in the area of blood supply to the recanalized CA. Meanwhile the condition of myocardial perfusion in the group of patients without restenoses did not undergo any noticeable changes. CONCLUSION: Myocardial perfusion scintigraphy using thallium-199 chloride allows to objectively evaluate over time the results of endovascular treatment of CAD. Also, there is every probability of success of predicting restenoses and stenoses de novo.

[Reperfusion syndrome after direct myocardial revascularization on beating heart in patients with ischemic heart disease. Possibilities of prevention with amlodipine]. / Vozmozhnosti profilaktiki reperfuzionnogo sindroma amlodipinom u bol'nykh ishemicheskoi bolezn'iu serdtsa, perenesshikh priamuiu revaskuliarizatsiiu miokarda na rabotaiushchem serdtse.

Possibilities of secondary prevention of reperfusion syndrome with amlodipine was assessed in 46 patients (39 with class III-IV angina after myocardial infarction and 7 with non ST elevation acute coronary syndrome). Twenty six patients received basic therapy, in 20 patients this therapy was supplemented with amlodipine (5-10 mg/day). In all patients complete direct arterial myocardial revascularization on beating heart was carried out. Methods of dynamic control included echocardiography, paired bicycle exercise tests, 6 minute walk test, myocardial scintigraphy with thallium-199. The results evidence for efficacy and feasibility of secondary prevention of reversible myocardial dysfunction with amlodipine.