The Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD) represents a focused update of the KDIGO 2020 guideline on the topic. The guideline targets a broad audience of clinicians treating diabetes and CKD. Topic areas for which recommendations are updated include: Chapter 1: Comprehensive care in patients with diabetes and CKD and Chapter 4: Glucose-lowering therapies in patients with type 2 diabetes (T2D) and CKD. Previous chapters on Glycemic monitoring and targets in patients with diabetes and CKD (Chapter 2), Lifestyle interventions in patients with diabetes and CKD (Chapter 3), and Approaches to management of patients with diabetes and CKD (Chapter 5) have been deemed current and their content has remained unchanged. Development of this guideline update followed an explicit process of evidence review and appraisal. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, and appraisal of the quality of the evidence and the strength of recommendations followed the “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) approach. Limitations of the evidence are discussed and areas of future research are also presented.

This review summarizes the current understanding of pathogenesis and the most important issues of pharmacological therapy of secondary hyperparathyroidism in patients with chronic kidney disease. Key factors of secondary hyperparathyroidism progression include hypocalcemia, hyperphosphatemia, and low levels of calcitriol. The first line treatment of secondary hyperparathyroidism is the use of a conservative approach, aimed at the correction of each of these factors. The review summarizes the experience of phosphate binders, vitamin D analogs, and calcimimetics usage in this category of patients. The mechanisms of action of these drugs are discussed, as well as treatment regimens aimed at achieving satisfactory control of mineral and bone metabolism and the risk of progression of severe hyperparathyroidism reduction.

Peritoneal dialysis (PD) uses the peritoneal membrane for dialysis. The peritoneal membrane is a thin layer of tissue that lines the abdomen. The lining is used as a filter to help remove extra fluid and poisonous waste from the blood. Everybody is unique. What is normal for one person’s membrane may be very different from another person’s. The kidney care team wants to provide each person with the best dialysis prescription for them and to do this they must evaluate the person’s peritoneal lining. Sometimes dialysis treatment itself can cause the membrane to change after some years. This means more assessments (evaluations) will be needed to determine whether the person’s peritoneal membrane has changed. Changes in the membrane may require changes to the dialysis prescription. This is needed to achieve the best dialysis outcomes. A key tool for these assessments is the peritoneal equilibration test (PET). It is a simple, standardized and reproducible tool. This tool is used to measure the peritoneal function soon after the start of dialysis. The goal is to understand how well the peritoneal membrane works at the start of dialysis. Later on in treatment, the PET helps to monitor changes in peritoneal function. If there are changes between assessments causing problems, the PET data may explain the cause of the dysfunction. This may be used to change the dialysis prescription to achieve the best outcomes. The most common problem with the peritoneal membrane occurs when fluid is not removed as well as it should be. This happens when toxins (poisons) in the blood cross the membrane more quickly than they should. This is referred to as a fast peritoneal solute transfer rate (PSTR). Since more efficient fluid removal is associated with better outcomes, developing a personal PD prescription based on the person’s PSTR is critically important. A less common problem happens when the membrane fails to work properly (also called membrane dysfunction) because the peritoneal membrane is less efficient, either at the start of treatment or developing after some years. If membrane dysfunction gets worse over time, then this is associated with progressive damage, scarring and thickening of the membrane. This problem can be identified through another change of the PET. It is called reduced ‘sodium dip’. Membrane dysfunction of this type is more difficult to treat and has many implications for the individual. If the damage is major, the person may need to stop PD. They would need to begin haemodialysis treatment (also spelled hemodialysis). This is a very important and emotional decision for individuals with kidney failure. Any decision that involves stopping PD therapy or transitioning to haemodialysis therapy should be made jointly between the clinical team, the person on dialysis and a caregiver, if requested. Although evidence is lacking about how often tests should be performed to determine peritoneal function, it seems reasonable to repeat them whenever there is difficulty in removing the amount of fluid necessary for maintaining the health and well-being of the individual. Whether routine evaluation of membrane function is associated with better outcomes has not been studied. Further research is needed to answer this important question as national policies in many parts of the world and the COVID-19 has placed a greater emphasis and new incentives encouraging the greater adoption of home dialysis therapies, especially PD. For Chinese and Spanish Translation of the Lay Summary, see Online Supplement Appendix 1.

Aim: to assess the possibility to conduct double mini-PET combined with standard PET (peritoneal equilibration test). The combination provides the complete assessment of the peritoneal membrane state during one visit; however, there are doubts whether the short exchange before a standard PET will distort its results. Methods: two standard PET and two combined double mini-PET with standard PET were consequentially performed in 21 stable patients on continuous ambulatory peritoneal dialysis (CAPD). The average patient’s age was 55±10 years; CAPD duration was 37±25 months. Dialysate-to-plasma creatinine ratio after 4-hour exchange (D/P4) differences for combined and performed separately PET were evaluated, accounting for the natural dynamics of peritoneal permeability. Results: the ratio D/P4 in the second separated test was 0.745±0.110, in the first combined test 0.740±0.100; over the time interval between tests (5.0±2.3 months), the average change in the individual values of D/P4 in the pairwise comparison was in terms of semi-annual change of 0.008±0.028. Thus, the systemic bias between the two measurements was 1.2%, and the random was 3.8%. The correlation between test results was 0.957; p<0.001). As part of analyzing the effect of the natural dynamics of peritoneum permeability on changes in the results, the changes in individual data were evaluated for the time interval between two standard and between two combined samples. The change in D/P4 between standard tests was 0.014±0.030 (system bias 1.9%, random bias 4.1%); between the combined tests 0.005±0.056 (system bias 0.7%, the random one 7.6%). Thus, the change in the D/P ratio after changing methods (and over a period of 5 months) did not exceed the natural dynamics of membrane permeability over similar periods when performing the same test. Conclusion: the combination of double mini- and standard PET does not distort the standard PET results, which allows using the capabilities of both test options with a reduction in logistic costs for the patient and dialysis center.

Objective: to analyze the clinical and morphological features, the effectiveness of immunosuppressive therapy, and the outcomes of ANCA-GN. Materials and methods: the study included 31 patients with a morphologically confirmed diagnosis of ANCA-GN, aged from 27 to 73 years. Clinical and morphological features, the effectiveness of immunosuppressive therapy, and outcomes were analyzed. Results: 5 patients were diagnosed with granulomatosis with polyangiitis, 5 with microscopic polyangiitis, 4 with ANCA-vasculitis with an indeterminate phenotype, and 17 with isolated ANCA-GN. During morphological diagnosis, all patients had elevated serum creatinine from 224 to 1520 mmol/l, and 13 required hemodialysis. Crescentic morphological type of ANCA-GN was found in 23 patients (74%), focal in 3, mixed in 3, and sclerotic in 2 patients. A significant direct correlation was found between creatinine levels and the percentage of crescents in the biopsy (r=+0.536; p=0.0019), as well as the percentage of interstitial fibrosis (r=+0.511; p=0.0033). Risk groups of unfavorable renal outcome according to the Brix index were identified: low 1, medium 14, and high-risk 16 patients. Immunosuppressive therapy with glucocorticosteroids and cyclophosphane pulses had a positive effect in 15 cases (48%). 11 (35%) died. Causes of death in 7 cases was an infection, in 5 cases COVID-19. The unfavorable outcome of ANCA-GN was significantly associated with a BVAS value of ≥24 points (p=0.044), with the presence of lung damage and hemoptysis (p=0.002). Renal survival was: 12-month 76%, 36-month 42%, and 60-month 30%. In the risk groups, the 36-month renal survival was: at low (0 points) - 100%, at average (2-7 points) - 83%, at high risk (8-11 points) - 23%. Renal survival significantly depends on the percentage of interstitial fibrosis (p=0.04) and BVAS (p=0.001). The overall survival rate for 12 months was 83%, 36 - 67%, 60 months - 52%. There was a significant association of overall survival with high vasculitis activity: BVAS ≥24 points (p=0.047) and the presence of lung lesions with hemoptysis (p=0.003). Conclusions: in ANCA-GN, renal survival depends on the % of interstitial fibrosis, and overall survival depends on the activity of vasculitis.

Objective: pregnancy in women with advanced chronic kidney disease (CKD) is associated with a high risk of adverse outcomes for the mother and the fetus. Setting of care is a potential determinant of the results, but data about pregnancy course in different settings are still limited. In this retrospective study, we aimed to analyze the course and outcomes of pregnancy in women with CKD stage 4 followed-up in a referral center in Russia. Materials and methods: thirteen pregnant women with CKD stage 4 were followed in a dedicated unit for pregnant women with kidney diseases. Main data collected: CKD cause, obstetric history, pre-gestational serum creatinine (sCr), week of gestation at the first visit, proteinuria, sCr and blood pressure (BP) at referral and each trimester, type and week of delivery and pregnancy outcome. Physiological kidney response to pregnancy was considered as a persistent decrease of SCr by ≥10 μmol/L from the pre-gestational level. Superimposed PE was diagnosed based on the abrupt increase of blood pressure, proteinuria and/or sCr, together with alteration of the angiogenic-antiangiogenic ratio, whenever available. Pregnancy management included BP control, anemia correction, antiplatelet and anticoagulant therapy, and urinary tract infection treatment. Results: arterial hypertension was present at referral in 6/13 cases, the mean BP decreased by the 3-rd trimester under treatment. Proteinuria increased during pregnancy in all cases, more rapidly in women who subsequently developed preeclampsia. Mean sCr at referral to the center was 184±13.3 μmol/L, urea 9.8±0.6 mmol/l, eGFR 32.9±2.9 ml/min/1.73 m2. Postpartum sCr increased to 243.4±37.8 μmol/L, urea 11.9±0.7 mmol/L, and eGFR dropped to 21.8±1.4 ml/min/1.73 m2. Median term of delivery was 34 weeks of gestation. Superimposed preeclampsia was diagnosed in 6 cases. All newborns were alive and viable. None of the patients needed dialysis during pregnancy or immediately after delivery. Conclusion: a favorable pregnancy outcome, defined as a viable baby without major health issues, is possible in women with CKD stage 4, however prematurity is common, and a decrease in the kidney function is observed in most of the cases.

Endovascular revascularization preferably used as initial treatment of chronic mesenteric ischemia, while the patients with mesenteric artery occlusive disease and aneurisms and those with multisite disease should undergo open surgical revascularization [1, 2]. Definite indications for revascularization in the patients with atherosclerotic renovascular disease and renal artery stenosis >75% are as follows: pulmonary edema, chronic kidney disease progression, renin-angiotensin system inhibitors intolerance, and acute kidney injury due to acute renal artery occlusion [3-6]. We report a case of successful surgical revascularization of celiac artery and superior mesenteric artery and endovascular revascularization of renal artery in the setting of multisite artery disease. 65-year-old female with a history of overweight (BMI 29 kg/m2), arterial hypertension, and pulmonary edema two months prior to admission, was admitted for BP 250/100 mm Hg on multi-agent therapy. Her urinalysis and total blood count were normal, serum creatinine (SCr) 193 µmol/L, glucose 8.6mmol/L, НbА1С 6.6%, and total cholesterol 9.6 mmol/L. Plain chest X-ray: aortic sclerosis and pulmonary circuit congestion. Kidney ultrasound: contracted left kidney. Echocardiography: aortic calcification, atrium dilatation, left ventricular hypertrophy with diastolic dysfunction. Separate renal veins (RV) blood sampling for renin levels: left RV - 54.3 pg/mL, right RV - 28.2 pg/mL (normal range 3.8-47.8). Angiography: right renal artery (RA) proximal stenosis 80-90%; left RA isthmic occlusion; celiac artery (CA) and superior mesenteric artery (SMA) occlusion, and inferior mesenteric artery (IMA) isthmic stenosis >80% (Figure 1A). Computed tomographic angiography: aorta, its visceral branches and lower extremity arteries atherosclerosis, proximal CA and SMA occlusion (9 mm and 30 mm respectively) with collateral blood flow through narrowed up to 80% IMA with massive anastomotic arches 2-5 mm at the pancreatic level and aneurism 7 mm at the proximal transverse colon level; left RA occlusion with severe kidney hypoperfusion (Figure 1B). Given CA and SMA occlusion with a high risk an acute disturbance of mesenteric circulation, and resistant arterial hypertension resulting from hyperreninemia due to severe hypoperfusion of the contracted left kidney, we decided to perform urgent surgical CA and SMA revascularization and simultaneous left nephrectomy. 27.12.2021 the patient underwent CA prosthetics, SMA bypass grafting (Figures 1C-1F ), and left nephrectomy; post-surgery period was uneventful and 2 weeks later she was discharged. We scheduled right RA stenting within a month but she did not show. Three months later, she arrived to emergency room complaining of right flank pain, vomiting and anuria, her SCr was 899 µmol/L, Duplex ultrasound revealed RA occlusion. She received two hemodialysis sessions and underwent urgent stent placement (Figures 2A-2D), resulted in immediate polyuria (9.6-8.5-4.5-2.0 L/24 h), rapid decline of SCr to 140 µmol/L, and BP decrease to 150/80 mm Hg. Eight months later her BP is controlled, stent is patent, and SCr is 113 µmol/L. Our patient with obesity, dyslipidemia, type 2 diabetes, multisite atherosclerosis with CA, SMA and left RA occlusion and IMA and right RA stenosis, had definite indications for right RA revascularization [6]. However, we postponed this intervention due to the high risk of acute disturbance of mesenteric circulation. Given multisite artery disease [1, 2] and increased renin excretion from contracted left kidney, we performed CA and SMA surgical revascularization and left nephrectomy first, and scheduled right RA endovascular revascularization. Acute right RA occlusion with anuria demanded urgent stent placement, which led the complete resolution of the acute kidney injury and good blood pressure control. Informed consent was obtained from the individual participant included in the study. None of the authors declares a conflict of interests.

Introduction Cardiac myxoma (CM) is the most common type of benign primary cardiac tumors [1]. In 90% of cases, it localized in the left atrium (LA) and attached to the left side of the atrial septum by mobile pedunculus [2, 3]. The patients with CM exhibit various clinical manifestations, ranging from systemic infections and vasculitis to life-threatening cardiovascular disasters. In frequently the patients with CM are quite asymptomatic, pathognomonic signs and symptoms are absent [1-3]. The patients with CM can complain about shortness of breath, fever, weight loss and fainting. Commonly CM manifests with embolism in systemic circulation by tumor fragments or blood clots from its surface [1, 3, 4]. Sometimes CM can manifest with life-threatening arrhythmias, mitral valvular, left ventricular or abdominal aorta obstruction. Echocardiography (Echo) is the first line imaging modality. The prognosis is excellent when treated with prompt surgical resection [1, 3, 4]. The clinical case of LA myxoma in a young female without any history of cardiac disease is presented. The peculiarity of the case is the clinical manifestation in the form of renal colic due to embolic kidney infarction. Clinical case 37-years old female was hospitalized due to intensive right-sided lower back and groin pain. Previously she considered herself healthy and led active lifestyle. Within the past several months she has been noticing unexplained weakness and lightheadedness. She underwent the medical checkup just before hospitalization, an emotional disorder was diagnosed. At admission the typical symptoms of right-sided renal colic were present. Laboratory tests were within normal ranges, except Pcr 125 mcm/L and D-dimer 500 ng/mL. Urolithiasis was ruled out after ultrasound and multispiral computed tomography (MCT). Contrast enhanced MCT with image postprocessing was performed (Fig. 1A, B ): In the right kidney, a decrease in the contrast of the lower two-thirds of the parenchyma and several areas of wedge-shaped enhancement defects that involved both the cortex and medulla were found. A thin rim of cortex was continuing to enhance, due to collateral capsular perfusion. The main renal artery, segmental and lobar branches were contrasting without defects. At heart auscultation on patient’s left side the three-part rhythm and short protodiastolic murmur were registered at the apex. The auscultation in standing position was unremarkable. Echo demonstrated the slow-moving mass 5.0×5.2 cm with mixed echogenicity and smooth contour. The mass occupied almost the entire LA and it was attached to atrial septum (Fig. 1C ). A single small floating element no more than 3 mm, was visualized upon a smooth contour. The patient was transferred to special hospital with a diagnosis of a heart tumor for further treatment. During the surgery the mass of a heterogeneous consistency 5.0×5.5 cm, attached to the free wall of LA and part of atrial septum by pedunculus 0.7×2.0 cm was revealed. The tumor with pedunculus was excised and completely resected within healthy tissue (Fig. 2A, B ). Histopathological assessment confirmed the diagnosis of CM: stellate and process cells in the myxomatous substance with numerous foci of hemorrhage (Fig. 2C ). The postsurgical period proceeded without complications. The indicators of Pcr and D-dimer returned to normal ranges (95 mcm/L and 100 ng/mL resp.) Conclusion The presented case demonstrates the embolic kidney infarction as a clinical manifestation of left atrial myxoma in previously health young female without any hemostatic disorders. The substrate of the embolism was a thrombus fragment from the tumor surface. The absent of contrast defect in renal artery due to contrast enhanced MCT and transient increase D-dimer confirmed thromboembolic genesis of kidney infarction and supported the high probability of spontaneous thrombolysis. The clinical picture at admission was indistinguishable from typical renal colic. The case demonstrates the need for a prompt and focused search for the cardiac origin of embolic syndrome regardless of patient’s age, previous health condition and involved arterial vessel. Informed consent for publication of patient's information and images was obtained from our patient. The authors declare no conflict of interest.

Infection caused by the Varicella zoster virus (VZV) is a significant problem for immunocompromised individuals such as patients receiving immunosuppressive therapy, patients with immunodeficiency or HIV infection. Most often, VZV infection in this group of patients represents a reactivation of chronic infection, in the form of herpes zoster with a possible generalization. However, primary infection is also possible with the development of chickenpox, which is often severe, and with the development of complications leading to death. The article represents a clinical case of severe chickenpox complicated by the development of sepsis and subsequent death in an adult patient with a kidney transplant on the background of immunosuppressive therapy. The disease proceeded atypically, with a four-day prodromal period and further rapid development of the clinical picture with the simultaneous presence of manifestations of typical, hemorrhagic, and visceral forms of chickenpox. The spread of the rash was also atypical - mainly on the head, upper extremities, and upper trunk. On the scalp and face the elements were represented by vesicles and pustules, and from the neck to the umbilical region - in the form of vesicles with hemorrhagic contents. Secondary bacterial infection of the rash elements was joined on the 3rd day from the appearance of the rash with the further development of the septic condition. The diagnosis was confirmed by PCR of the contents of the pustules and the absence of IgG class antibodies to the Varicella zoster virus. The generalization of secondary bacterial infection was confirmed by seeding the same pathogens in the contents of pustules and urine. Against the background of ongoing therapy, which included the use of acyclovir and massive antibacterial therapy, the patient's condition continued to deteriorate, and on the 9th day from the disease onset, a fatal outcome occurred. This clinical case demonstrates the possible difficulties in the diagnosis and management of chickenpox in immunocompromised patients, and emphasizes the need to develop and implement preventive measures for this cohort of patients.

Granulomatous tubulointerstitial nephritis (GTIN) is the rarest form of acute tubulointerstitial nephritis (ATIN) and, therefore, may present with acute kidney injury (AKI). GTIN accounts for only 0.5-0.9% of cases in the spectrum of native kidney biopsies, 0.6% in graft biopsies, and 6% in nephrobiopsies in interstitial nephritis. Identification of this morphological variant of ATIN obliges the physician to conduct a differential diagnosis between diseases characterized by the development of granulomatous inflammation in different organs, which is often associated with significant difficulties. The presented observation of GTIN in a 57-year-old patient without a history of chronic kidney disease (CKD), with newly diagnosed type 2 diabetes mellitus and developed AKI after the start of therapy with modern hypoglycemic drugs from the group of sodium-glucose cotransporter-2 inhibitors (iSGLT-2) - dapagliflozin and the glucagon-like peptide-1 receptor agonist (GLP-1 RA) - semaglutide examination which led to the diagnosis of sarcoidosis with lesions of the lungs, intrathoracic and intra-abdominal lymph nodes, illustrates the complexity of the diagnostic search in such cases. The granulomas found during the morphological examination of the kidney biopsy did not have signs of caseous necrosis and were combined with diffused eosinophilic infiltration of the renal interstitium, which made it even more difficult to differentiate between GTIN of drug-induced etiology and sarcoidosis kidney damage. The key feature of the disease was the unresolved AKI after the discontinuation of antidiabetic drugs by the patient, and newly diagnosed sarcoidosis, both of which served as the reason for determining the leading cause of GTIN in the presence of two likely triggers - drug-induced kidney injury and systemic granulomatous disease. A thorough analysis of the clinical and morphological manifestations of the disease led to the conclusion that granulomatous lesions of the interstitium have combined genesis. The features of the course of GTIN in sarcoidosis and drug-induced kidney injury are also discussed. It is noted that the presented observation is the first description of the GTIN case when using a combination of drugs from the iSGLT-2 and GLP-1 RA groups. In connection with the simultaneous appearance of AKI and signs of sarcoidosis, the possibility of developing a drug-induced sarcoidosis-like reaction is discussed. Difficulties in isolating the leading factor in the development of the disease, in this case, did not prevent the initiation of pathogenetic therapy with systemic corticosteroids with the achievement of a rapid effect: a decrease in blood creatinine and a positive clinical and radiological dynamics of the pulmonary process were noted.