New normative documents of Government, Health care ministry and Federal fund for compulsory health insurance issued in December 2016 substantially change the conditions for the medical aid administering - particularly - in the field of renal replacement therapy. The potential consequences and necessary actions are discussed. New lists of Diagnosis-Related Groups were set up separately for in-patient and day hospital condition of medical care render. Dialysis sessions can be reimbursed as the unit of healthcare in condition of hospital (day hospital) admittance or in outpatient condition. The necessary medicinal therapy of CKD G5D syndromes can be reimbursed within the framework of DRG 40 (DRG 41) which provides one month patient management or be provided by budgetary funded system of Supplementary Drug Providing, accordingly. The different recommended tariffs (enlarged by 4,28% from year 2016) for hemodiafiltration, automated peritoneal dialysis, prolonged renal replacement therapy and others were established; the prices should not depend on condition of healthcare render. The DRG 112 (for inpatient condition) and DRG 42 were established for dialysis access placement.

Despite a significant decrease in the prevalence of chronic HCV-infection among patients receiving renal replacement therapy, it is still a challenge, primarily for patients in a waiting list and after kidney transplantation, because HCV-infection adversely affects both recipient survival, and the duration of the graft functioning. The use of antiviral therapy with interferon has limited effect due to a significant number of serious adverse events in the dialysis population. Besides, it was shown to be dangerous for kidney transplant recipients because of the high risk of irreversible rejection. Prescription of ribavirin, on the contrary, was considered inappropriate for patients on hemodialysis, because of the possibility of worsening of renal anemia. The introduction of modern direct antiviral drugs into clinical practice has radically improved the efficacy and safety of the treatment of chronic HCV-infection. However, the use of these drugs in patients with severe renal dysfunction is quite specific primarily due to the possibility of adverse drug-drug interaction with immunosuppressors in kidney transplant recipients. In this review, we consider the development of chronic HCV-infection and the prognosis in patients on renal replacement therapy, as well as the opportunities, conditions and tactics for the new antiviral therapies in this patient population.

Vascular endothelial growth factors which promote angiogenesis and vasculogenesis play a major role in human physiology and pathology. They affect the function of the endothelium, promote angiopoietins in the fetus, contribute to the formation of the primary blood vessels and in adults, contribute to the healing of wounds, improve collateral circulation in myocardial infarction and accelerate the rehabilitation of patients. At the same time, angiopoietins induces a number of adverse effects: progression of diabetic retinopathy, macular degeneration of the retina, accelerate growth and metastasis of cancer. This review presents data on the role of angiopoietins (VEGF-A, ANGPTL4) in the pathogenesis of the major manifestations of nephrotic syndrome - proteinuria, oedema, dyslipidaemia. It was demonstrated that the expression of hyposialylized of ANGPTL4 in podocytes is capable to induce the development of nephrotic syndrome in the patients with diabetic nephropathy and minimal changes glomerulonephritis. However, with continued loss of protein in the urine increases of expression of ANGPTL4 in the heart, liver, muscles and reduces proteinuria, but exacerbates hypertriglyceridemia. However, the mutant forms of ANGPTL4 are capable to induce a remission of nephrotic syndrome without degrading of the lipid profile. Prescription of N-acetyl-D-mannosamine to patients with nephrotic syndrome is able to transform hyposialylized ANGPTL4 into a normal ANGPTL4, significantly reduce proteinuria and prevent recurrence of nephrotic syndrome.

The aim: to evaluate the percentage of sudden cardiac death (SCD) in dialysis population and its relation to the QTc duration as a fatal arrhythmia factor and the predictors for its duration at baseline, during dialysis session and during follow-up. Patients and method: SCD percentage was evaluated in 1229 cases of death. In prospective follow-up research, 159 patients in one dialysis center, the QTc duration was measured three times with 5 months interval. Results: in 45% cases of sudden death occurred in average after 31 (10÷65) months of dialysis compared with 36 (21÷68) months in non-SCD cases and 41 (13÷76) months among alive patients. The cases of SCD have uniform distribution during the week while non-SCD cases were shifted towards long interdialytic interval (p=0.044). QTc was prolonged in 17% of patients and was longer in hyperphosphatemia (p=0.04) and at higher comorbidity; the higher LVMI (by 10 g/m2) was linked with longer QTc (by 6-7 msec); QTc correlated with end-diastolic volume (r=+0.264; p=0.002), with end-systolic volume (r=+0.372; p<0.001), with left atrium diameter (r=+0.172; p=0.05). A prolongation of QTc during the dialysis session (+6±35 msec; p=0.059) was associated with ultrafiltration (r=0.23; p=0.01) and potassium level higher than its median level of 5.13 mM (+8±26; p<0.05). In follow-up period, the stable QTc duration correlated with higher calcemia and phosphatemia (p<0.05). Conclusion: SCD is frequent in dialysis patients; QTc measurement enables one to assess the risk of fatal arrhythmia. The duration length and the prolongation of QTc in dialysis session and during follow-up are associated with preventable and modifiable factors (cardiac remodeling, fluid and ionic balance, mineral and bone disorders parameters).

The aim: to evaluate arterial blood pressure (BP) measurement in different phases of “dialysis” week and its dynamics as a prognostic factor. Patients and method: 133 patients of a dialysis center were assessed in three years prospective study in conjunction with blood pressure measurement before, during, and after dialysis session and in the interdialytic interval as well as its changes during the study. Results: BP in most of patients decreases during dialysis session (by 6.9 mm Hg) and continues to decrease during interdialysis interval (by 2.2 mm Hg). BP before session was 139±19/81±12 mm Hg, being in target range (140/90 mm Hg) in 59% of women and 49% of men. Two year survival (Kaplan-Meier) was not associated with predialysis and intradialysis BP; the difference of survival was close to significance while comparing lower tertile of postdialysis BP with the rest of the group (p=0.08). Interdialysis BP higher than 123 mm Hg (the border between lower and medium tertile) divides patients by survival (p=0.04); this difference was the most significant while dividing by the border of 127 mm Hg (χ² in Log-Rank test = 4.77; р=0.029). During the study all parameters of BP decreased significantly, but only for interdialysis BP the positive dynamics was associated with better survival (p=0.019). Conclusion: The interdialysis BP and its dynamics during correction are significantly associated with survival while the peridialysis BP and its dynamics are not.

Severe proteinuria that develops or increases during pregnancy may be a symptom of both glomerular diseases (in particular, glomerulonephritis) or preeclampsia (PE). The differential diagnostics was difficult until recently. In the article we use a real clinical case to discuss important aspects of the differential diagnosis between these two types of pathology during pregnancy by determining levels of angiogenic factors - vascular endothelial growth factor (VEGF), placental growth factor (PlGF) and their antagonist - soluble fms-like tyrosine kinase-1 (sFlt-1). The determination of the balance of placental growth factors and their receptors is not only a modern, non-invasive not expensive method of early diagnosis of preeclampsia. It is also a reliable method of the discrimination between primary renal diseases and obstetric pathology in patients with increasing proteinuria during pregnancy, which will determine the management of pregnancy in patients with renal diseases. It is proposed to include the determining the balance of angiogenic and antiangiogenic factors to the list of mandatory methods for screening of pregnant women with renal diseases since the second trimester.

Aim: to compare the levels of angiogenic and antiangiogenic factors in different periods of pregnancy complicated or not complicated by PE, in patients with CKD and assess the significance of sFlt-1/PlGF ratio in the prediction and diagnosis of PE in women with kidney disease. Methods: in 130 pregnant women with CKD at different stages, the gestation serum levels of sFlt-1 and PlGF have been determined, and the sFlt-1/PlGF ratio was calculated and compared in patients with and without PE. To determine the prognostic value of the sFlt-1/PlGF ratio, the ROC-curves were plotted and the quality of prognosis was assessed. Results: in CKD patients who develop PE compared with women without PE, the median PlGF in the second trimester of pregnancy were significantly lower - 134 (7-2113) pg/ml vs 317 (59-2203) pg/ml, p=0.001, and the median sFlt-1/PlGF ratio was significantly higher: 9.87 (1.86-701) vs 4,57 (0.69-19.2), p=0.001. sFlt-1/PlGF ratio was substantial increased in the second trimester in women with early (before 34 weeks gestation) PE compared to patients without PE: 30.1 (2.37-701) vs 4.66 (0.79-17.1), p=0.00009. In patients with PE an upward trend in sFlt-1/PlGF ratio was observed 5 weeks before delivery, while 3 weeks before delivery it was significantly higher than the that for uncomplicated pregnancy. An increased risk of PE was observed in the individual values of the sFlt-1/PlGF ratio above 6.3 in the second trimester of pregnancy, and PE developed in all pregnant women with the ratio above 20.7. Conclusions: an assess of the sFlt-1/PlGF ratio is a powerful method of prediction and early diagnosis of PE in pregnant patients with CKD.

Alport syndrome is a rare genetic disease characterized by progressive CKD and abnormalities of the hearing and vision. It is also known, that Kaposi’s sarcoma is one of the most common neoplasia in patients after kidney transplantation. The use of immunosuppressant drugs, genetic predisposition and viral infection (human herpesvirus-8) is also associated with post-transplant malignancy. We report a case of simultaneous occurrence and treatment of Kaposi's sarcoma in mother and son with Alport syndrome in the early post-transplant period. Chemotherapy with doxorubicin and conversion to everolimus was used. Our patients have been followed up for two years without any recurrence and with well functioning graft. Everolimus is an immunosuppressive agents, it is an inhibitor of the mammalian target of rapamycin (mTOR) that have specific antiproliferative effects. This observation reflects current interest in the role of mTOR inhibitors in the management of post-transplant tumors - Kaposi's sarcoma.

A case of interstitial pneumonia in a patient with the chronic rejection of kidney transplant is presented. Criteria for diagnosis were: medical history (chronic rejection of transplant in 3 months after transplantation; positive results of CMV, Mycoplasma, Toxsoplasma samples); critical parameters of the respiratory status on admission (expressed excitement, auxiliary muscles participating in breathing with rate higher than 30 per min, increasing cyanosis with SO2% and PaO2 higher than 70 mmHg); X-ray have shown bilateral subtotal infiltrative damage of both lungs. By analyzing clinical situation with the development of acute respiratory distress syndrome on the background of expressed damage of the immune status of patient and the progression of multi-organ failure, we used an available arsenal of replacement therapy and intensive care with positive results. Opportunities and benefits of using intrapulmonary percussion ventilation and non-invasive ventilation in respiratory therapy complex were found. Medication with FarGALS that has strong antiseptic activity and wide spectrum of antimicrobial effect (against Gram-positive and Gram-negative, aerobes and anaerobes, non spore-forming and spore-forming bacteria, fungi of the genus Candida) was used with therapeutic tracheo-bronchial lavage. The use of integrated approach with the use of hemodialysis, non-invasive respiratory methods with original antibacterial therapeutic lavage of the respiratory tract may be the alternative treatment tactic in this group of patients.