[Management of the patient with renal artery fibromuscular dysplasia: clinical case].

Fibromuscular dysplasia (FMD) is a rare disease that affects small and medium-sized arteries. Clinical manifestations of FMD depend on its localization. In many cases, FMD of renal arteries (RA) is associated with arterial hypertension. Young age, particularly of female patients, suspected RA dissection or kidney infarction, absence of atherosclerosis or presence of FMD in other arteries of such patients evidence for RA FMD. In invasive treatment of hemodynamically significant stenoses, transluminal balloon angioplasty (TBA) of renal arteries is preferrable. Taking into account initial alterations of the vascular wall and unevenness of the lumen of the affected blood vessel, stent implantation is associated with an increased risk of complications and is recommended only if ballooning complications develop. An open reconstructive surgery is indicated in complicated narrowing anatomy, a high risk of the endovascular treatment, or after failure of the endovascular intervention. This article presents a clinical case of a young female patient with RA FMD and renovascular arterial hypertension who successfully underwent renal TBA with a drug-coated balloon.

[The role of major vessels remodeling in development of left ventricular hypertrophy in patients with a predialysis stage of chronic renal failure].

AIM: To study correlation between development of left ventricular hypertrophy (LVH) and remodeling of major arteries at a predialysis stage of chronic renal failure (CRF). MATERIAL AND METHODS: A total of 95 non-diabetic patients (48 males-51% and 47 females-49%) with stage I-III CRF entered the trial. A mean age of the patients was 46.7 years (95% CI 43.7-49.8 years). Glomerular filtration rate calculated by Cockrott-Gault formula was 37.7 ml/min (33.9-41.4 ml/min), blood creatinine level--2.9 mg/dl (2.6-3.2 mg/dl). Arterial hypertension (AH) was registered in 96% patients, smoking--in 40%, cardiovascular hereditary burden--in 54%, hyperlipidemia--in 66%, overweight--in 60%, anemia--in 34%, hyperphosphatemia--in 45%. Echocardiography, ultrasonic dopplerography of the common carotid arteries (CCA) and common femoral artery (CFA) were performed in 83 and 37 patients, respectively. RESULTS: LVH (LV myocardium mass index > 134 g/m2 for males and > 110 g/m2 for females) was detected in 37.3% patients. Concentric remodeling was recorded in 31.3%, concentric myocardial hypertrophy--in 19.1% patients, excentric hypertrophy--in 18.1%. Development of LVH was linked with age, high systolic and pulse blood pressure, marked renal dysfunction, anemia, elevated ESR and hyperphosphatemia. The presence of L VH correlated with increased thickness of intima-media complex (IMC) of CCA and CFA (r = 0.65, p < 0.01 and r = 0.51, p < 0.05, respectively). There was correlation between thickness of LV posterior wall and impairment of CCA elasticity (r = -0.42, p < 0.05). CONCLUSION: Patients with initial and moderate disorders of renal function frequently have LVH related to conventional and "renal" risk factors. A LV mass increase and structural-functional changes of major vessels strongly correlate.

[Clinicomorphological features of nephropathy in primary and secondary antiphospholipid syndrome].

AIM: To investigate specific features of extrarenal manifestations of antiphospholipid syndrome (APS) in patients with APS-associated nephropathy (APSN) in primary APS and lupus nephritis (LN) with secondary APS; to compare clinicomorphological signs of APSN in primary and secondary APS. MATERIAL AND METHODS: We examined 44 APSN patients with primary APS and 90 patients with LN: 57 with secondary APS, 33 with antiphospholipid antibodies (APA) without history of thrombosis. In addition to clinical and immunological examination, detection of serological APS markers, morphological examination of renal tissue and ultrasound dopplerography (USDG) of the renal vessels were made (in some patients) for assessment of the condition of intrarenal vascular bed. RESULTS: In patients with primary APS, renal disorder and secondary APS in LN frequency of arterial thrombosis doubles that of venous ones. Renal disorder irrespective of a clinical APS form (primary, secondary) combines with affection of the CNS, heart and skin (livedo). This correlates with frequency of arterial thrombosis. In patients with primary APSN rate of arterial hypertension (AH), especially severe, and renal dysfunction is higher than in LN with APS while this group is characterized by more severe proteinuria, microhematuria and higher incidence of nephrotic syndrome. A direct correlation exists between the incidence of arterial thrombosis and severity of AH, between AH and renal ischemia by USDG. Morphologically, glomerulosclerosis, marked arteriolosclerosis and diffuse interstitial sclerosis occur more often in patients with primary APSN compared to LN patients with APS. CONCLUSION: In primary and secondary (in SLE) APS combination of APSN with impairment of the CNS, heart and skin, correlation of its basic clinical manifestations with arterial thrombosis allow us to single out a special clinical variant of APS manifesting with generalized ischemic lesions of the organs as a result of arterial/arteriolar thrombosis. Irrespective of its nature, APSN has common characteristic features--combination of AH, persistent renal dysfunction and transitory hypercreatininemia--correlating with development of arterial thrombosis; therefore, this pathology can be considered as a variant of thrombotic vascular lesion of the kidneys.

[Risk factors of vascular complications in patients at a predialysis stage of chronic renal failure].

AIM: To specify risk factors of vascular complications at a predialysis stage of renal failure. MATERIAL AND METHODS: The trial enrolled 165 patients with chronic renal failure (CRF) aged 46 +/- 15 years, glomerular filtration rate (GFR) - 37.2 (35.02-40.83) and arterial hypertension (96%). The examination included ultrasound dopplerography of the common carotid arteries (CCA) and common femoral arteries (CFA) for detection of atherosclerotic plaques (AP), estimation of the thickness of arterial intima-media, elasticity and rigidity of the vascular wall. Factors of risk for atherosclerosis and cardiovascular complications were assessed. RESULTS: Aortic atherosclerosis was detected in 60 patients, that of cardiac vessels, brain, kidneys and lower limbs - in 35, 30, 23 and 8 patients, respectively. Acute cardiovascular complications occurred in 13 patients. Main atherosclerosis risk factors were age, body mass index, systolic and pulse arterial pressure, disturbances of phosphorus-calcium metabolism. Structure and function of CCA and CFA were studied with dopplerography in 37 CRF patients. Increased intima-media thickness was associated with age, male sex, overweight, hypercholesterinemia, systolic and pulse arterial pressure. Body mass index, GFR, creatinin level were independent factors of intima-media thickness. Abnormal elasticity of CCA was related to hypertension, CFA - to hypercholesterolemia.

[Factors influencing the condition of the intima-media complex of carotid and femoral arteries at initial stages of chronic renal failure].

AIM: To examine changes in the structure of large (carotid and femoral) arteries at an early stage of chronic renal failure (CRF) and factors significant for their development. MATERIAL AND METHODS: Duplex ultrasonography of the common carotid arteries (CCA) and common femoral arteries (CFA), serum biochemical tests, echocardiography were made in 32 patients (15 males and 17 females) with chronic diffuse renal disease at an initial stage of CRF (creatinine 2.7 mg%, CRF duration 2.7 years). Increased thickness of the intima-media complex (IMC) in both vascular territories was found in 72% of the examinees. There was a close correlation between CCA and CFA IMC (chi-square = 14.05; p = 0.0002). Plaques in the carotid arteries correlated with smoking (chi-square = 4.60; p = 0.0320), in the femoral arteries--with male sex (chi-square = 5.18; p = 0.0228). IMC of both arteries correlated with age (r = 0.49 and r = 50, respectively, p < 0.05), body mass index (r = 0.50, p < 0.05), thickness of the left ventricular posterior wall and interventricular septum (r = 0.65 and r = 0.55, respectively, p < 0.05), CFA IMC correlated also with creatinine level (r = 0.39, p < 0.05), hypertriglyceridemia (chi-square = 10.33; p = 0.0013), systolic, pulse and mean arterial pressure (r = 0.45, r = 0.38, r = 0.36, respectively, p < 0.05), smoking (r = 0.48, r = 0.40, respectively, p < 0.05) and family history of cardiovascular diseases (chi-square = 7.16; p = 0.0075). A linear multifactorial regression analysis has detected that an independent factor of increased CCA and CFA IMC in patients under 50 years of age was creatinine, in patients over 50 years--age. CONCLUSION: Even at early stages of renal failure patients have thicker IMC associated with both standard risk factors (age, hypertension, smoking, lipid disbolism) and development of renal failure itself.

[Calcification of peripheral arteries in patients with terminal renal failure on programmed hemodialysis].

AIM: To estimate incidence and clinical significance of carotid and femoral arteries calcification in patients with terminal renal failure (TRF) on programmed hemodialysis (PH). MATERIAL AND METHODS: Thirty four patients (25 males and 9 females) with TRF were divided into two groups by severity of hyperphosphatemia: 15 patients with P < 6 mg/dl (group 1) and 19 patients with P > 6 mg/dl. The groups were matched by age (44.4 +/- 15.05 and 42.7 +/- 14.23 years, respectively) and PH duration (2.4 +/- 1.1 and 2.6 +/- 1.16 years, respectively). Calcification of the arteries and structure of the vascular wall were examined with ultrasonic dopplerography of the common carotid and femoral arteries. Measurements were made of intima-media complex (IMC) thickness, systolic and diastolic diameter of the right and left carotid artery. The arteries were studied for the presence of calcinates and atherosclerotic plaques. RESULTS: Patients of group 2 showed a correlation between a P level, incidence rate of common carotid arteries calcification, atherosclerotic plaques in the femoral arteries, IMC of the carotid and femoral arteries, left ventricular hypertrophy and a decline in a left ventricular diastolic function. A significant correlation was established between the rate of atherosclerotic plaques detection and age, male sex, smoking and history of PH. An increase in IMC and arterial rigidity was revealed in 12 (63.2%) of 19 patients of group 2. They had episodes of intradialysis hypotonia, 6 (31.6%) patients had acute coronary syndrome, 5 (26.3%) patients--cardiac arrhythmia. CONCLUSION: A significant contribution to formation of risk factors of cardiovascular complications in TRF patients on PH is made by disturbed phosphorus-calcium metabolism resulting in higher rigidity and diameter of the arteries. The above changes lead to a rise in systolic pressure and fall in diastolic one. Increased pulse pressure is an independent predictor of the risk to develop acute coronary syndrome.

[Low-molecular heparins in the treatment of APS-nephropathy in primary and secondary antiphospholipid syndrome]. / Nizkomolekuliarnye gepariny v lechenii AFS-nefropatii pri pervichnom i vtorichnom antifosfolipidnom sindrome.

AIM: To evaluate efficacy of low-molecular heparin enoxaparin in the treatment of nephropathy in patients with primary and secondary antiphospholipid syndrome (APS). MATERIAL AND METHODS: A total of 11 APS-nephropathy patients participated in the study. Of them 8 patients had primary APS and 3 patients had secondary APS. Biopsy of the kidney was made in 5 patients, ultrasonic dopplerography of renal vessels was performed in all 11 patients. Enoxaparin was given as monotherapy to primary APS and combined treatment to secondary APS patients. RESULTS: Enoxaparin decreased proteinuria, arterial pressure, glomerular filtration rate in all the patients. It also promoted normalization of creatinin. Before the anticoagulant treatment a reduction of maximal systolic and diastolic velocities of blood flow have been registered in segmental and interlobar arteries in all APS nephropathy patients compared to healthy subjects. The depletion of renal cortex blood flow beginning with the level of arcuate arteries was also observed in all the patients. Enoxaparin enhanced blood flow in segmental and interlobar arteries. The recovery of blood flow in the arcuate arteries was registered in 6 of 9 patients. CONCLUSION: Low molecular heparin may be used in the treatment of nephropathy in patients with primary and secondary APS.

[Role of ultrasound dopplerography with acute captopril test in assessment of renal hemodynamics in chronic glomerulonephritis]. / Pol' ul'trazvukovoi dopplerografii s ispol'zovaniem ostroi farmakologicheskoi proby s kaptoprilom v otsenke pochechnoi gemodinamiki pri khronicheskom glomerulonefrite.

AIM: To examine blood flow in renal and intrarenal arteries and its changes in the acute pharmacological test with captopril in patients with chronic glomerulonephritis (CGN). MATERIAL AND METHODS: Renal circulation was studied in 50 patients with CGN using ultrasound dopplerography (USDG) of renal vessels on the unit GE Logiq 400 CL PRO Series. The velocity and indices of peripheral blood resistance in the major renal artery (RA) and in intrarenal arteries were estimated. In 26 patients the blood flow was studied again after intake of 50 mg captopril. RESULTS: Poor renal blood flow was registered in cortical parenchyma in 36% CGN patients (with chronic renal failure in 75%). Multifactorial regression analysis has demonstrated that only blood creatinine was independently related with slowing down of the blood flow at the level of RA and intrarenal arteries. Morphological index of activity correlated with resistance indices while a high sclerosis index correlated with blood flow slowing. Older patients had higher resistance indices. Captopril significantly accelerated blood flow and insignificantly changed indices of peripheral resistance including those in CRF patients. CONCLUSION: Poor blood flow in the cortical layer of renal parenchyma in CGN, according to USDG, occurs rather frequently and was associated with CRF and older age of the patients. Blocking of renin-angiotensin system at the level of angiotensin II formation improves renal blood flow in most of the patients.