[Difficulties in the differential diagnosis of kidney injury in a patient with infective endocarditis associated with antineutrophil cytoplasmic antibodies]. / Trudnosti differentsial'noi diagnostiki porazheniia pochek u bol'nogo infektsionnym éndokarditom, assotsiirovannym s antineitrofil'nymi tsitoplazmaticheskimi antitelami.

Infective endocarditis (IE) may be accompanied by the production of a broad spectrum of autoantibodies, including antineutrophil cytoplasmic antibodies (ANCA). ANCA detection creates difficulties in the differential diagnosis of IE, especially in relation to kidney injury, the determination of the mechanism of which is important for choosing a treatment policy and estimating a prognosis. The paper describes a clinical case of a 57-year-old man who was found to have higher proteinase-3 (PR-3) ANCA titers along with the symptoms of anemia, purpura, and kidney injury during his hospitalization; echocardiography revealed vegetation on the aortic valve. IE was diagnosed; 2-week antibiotic therapy was ineffective; there was progressive aortic insufficiency necessitating aortic valve replacement. In the postoperative period, there was progression of renal failure and higher PR-3 ANCA titers, which made it possible to regard kidney injury as a manifestation of ANCA-associated glomerulonephritis. Intensive immunosuppressive therapy with intravenous and oral prednisolone was initiated, which showed positive effects in reducing proteinuria, erythrocyturia, serum creatinine levels, and simultaneously PR-3 ANCA titers. The paper gives the data available in the literature on the frequency of an association of IE with ANCA, the clinical features, diagnostic criteria, and treatment approaches. It discusses the mechanisms of ANCA formation in patients with IE.

[Specific damage to the kidneys in patients with chronic hepatitis C associated with cryoglobulinemia].

AIM: To reveal clinical and morphological characteristics of renal damage in patients with cryoglobulinemia (CGE) associated with chronic viral hepatitis C (CVH-C) for upgrading diagnosis, prognosis and optimization of the treatment methods. MATERIAL AND METHODS: Two groups of CVH-C patients were studied: with CGE (group 1, n = 64) and free of CGE (group 2, n = 62) matched for gender, age and duration of the disease. Biopsy of the liver for assessment of the histological activity index and histological sclerosis index by METAVIR scale was conducted in 63 patients. Of patients with CGE-related damage to the kidneys, 48 were examined for clinical picture with morphological investigation of renal tissue in 15 of them including semiquantitative evaluation of fibrosis degree and activity. RESULTS: Patients with CVH-C and CGE had a wider spectrum of systemic lesions than CVH-C patients without CGE. Only CGE patients demonstrated more severe affection of the skin, joints, kidneys and the nervous system. Therefore, CGE can be considered as a marker of poor prognosis. Liver biopsy showed that CGE patients had more pronounced fibrosis (3-6 points) versus 0-2 points in 80% patients from group 2. Duration of CVH-C from probable infection to renal damage in 48 patients with CGE glomerulonephritis (GN) averaged 197.05 +/- 18.5 months. Renal biopsy diagnosed CGE mesangiocapillary GN in 13 patients and membranoproliferative GN in 2 patients. Patients with HCV infection had a more severe proliferative form of nephritis--mesangiocapillary GN. In 48 GN patients with HCV-infection and CGE, GN ran latently with moderate urinary syndrome in 29 (60.4%) patients, with nephrotic syndrome--in 9 (18.6%), with acute nephritic syndrome--in 10 (21.0%) patients. Most of the patients had arterial hypertension, 13 patients had creatinemia (3.02 +/- 0.55 mg/dl), rapidly progressive GN was diagnosed in 4 patients. CONCLUSION: Persistent CGE marks poor prognosis in CHC patients and is an indication for antiviral treatment to prevent severe organ lesions, first of all of the kidneys. Development of CGE vasculitis with severe damage to the kidneys demands immunosuppressive therapy in combination with plasmapheresis or cryapheresis followed by antiviral drugs. As shown by pilot results, a new approach with rituximab is perspective but further evidence is needed for final conclusions.

[Vascular purpura in patients with chronic diffuse hepatic diseases].

The purpose of the study was to evaluate clinical significance of vascular purpura (VP) in diagnostics and establishing prognosis of chronic diffuse hepatic diseases (CDHD). The subjects were 660 patients with CDHD of viral and non-viral origin, who were under long hospital observation. 72 CDHD patients had cutaneous vasculitis. 11% of CDHD patients developed VP, which corresponded to the frequency of other cutaneous manifestations--minor hepatic signs (palmar erythema, spider-like blood vessels in the skin, xanthelasmas etc.) There was insignificant difference in the frequency of VP between the patients with type B and C hepatitis (9.6%), on the one part, and patients with non-viral hepatic diseases--primary sclerosing cholangitis, autoimmune hepatitis, and Wilson-Konovalov disease (14.2%). According to morphological data, 84.3% of CDHD patients with VP developed the latter or had a VP relapse at the cirrhotic stage (50%) or at the stage of forming hepatic cirrhosis (34.3%). Renal involvement, which was significantly more frequent in CDHD patients with VP vs. patients without VP (32% and 11.4%, respectively), may deteriorate the prognosis. The authors conclude that cutaneous vasculitits is a universal sign of viral and non-viral CDHD, which should be taken into consideration when diagnosing and establishing prognosis of these diseases. The fact that VP is revealed mainly at the cirrhotic stage suggests that an important role in its development is played by dysfunction of the liver, one of the main organs that clear antigen and immune complexes (including those of viral origin), appearing via the portal system or circulating in blood.

[Vascular purpura associated with chronic diffusive hepatic pathologies]. / Sosudistaia purpura, assotsiirovannaia s khronicheskimi diffuznymi zabolevaniiami pecheni.

The study results related with the rate of vascular purpura in 660 patients with different-type chronic diffusive hepatic pathologies both of the viral and other natures are described in the paper. The main regularities characterizing the phenomenon (spread and possible cause of purpura development) are defined. According to an analysis of actual materials, dermal vasculitis is not an exclusive feature of virus-associated hepatitis or liver cirrhosis. Vascular purpura can be regarded, on the basis of the obtained data, as a universal sign typical of any liver pathologies.