Перенести в английский вариант BACKGROUND. Hyperphosphatemia in CKD is spread widely, represents as independent factor of mortality at all stages of CKD, after transplantation, reduces the effectiveness of nephroprotection, leads to vascular calcification, stimulates hyperparathyroidism. Achieving the phosphatemia target is a difficult task and is based on a combination of a hypophosphate diet, effective dialysis, the antihyperparathyroidic measures and the phosphate-binders (PBs). THE AIM. The aim is to evaluate the effectiveness of sevelamertherapy in real clinical practice as part of a hypophosphatemic strategy with clarification of the conditions and measures under which it is optimal. PATIENTS AND METHODS. In an eight-month study in a region where there are no restrictions on access to calcium-free PBs, 127 patients were included in the study after the "washing period ": the of sevelamer doses were titrated until phosphatemia reaches below 1.58 mmol/l in parallel with individual measures of four-component hypophosphatemic strategy. RESULTS. From the starting dose of 3-6 tablets/day, 38 patients experienced either dose increase (+ 1016 ± 760 mg) or in 28 patients– decrease (- 1427 ± 1059 mg). By the third month of therapy, the proportion of patients with phosphatemia < 1.58 mmol/l reached 70 %, < 1.78 mmol/l – 90 %. The decrease magnitude depended on the initial phosphatemia, the level of PTH (maximum in the range of 150-600 pg/ml), occurs more slowly in men. During therapy, there was a decrease in the need for antihyperparathyroid therapy in the absence of dynamics in the parathyroid hormone level. In multiple regression analysis models, the independent factors associated with phosphatemia during treatment were sevelamer dose, dialysis dose, baseline phosphate and parathyroid hormone levels; the magnitude of phosphatemia reduction was independently associated with sevelamer dose, dialysis dose, baseline parathyroid hormone level, and assessment of treatment compliance. CONCLUSION. Sevelamer in a moderate well–tolerated doses as part of an individualized hyperphosphatemia correction strategy is able to achieve target phosphatemia (< 1.58 mmol/L) in 70 % of cases, and relatively safe level (< 1.78 mmol/L) – in 90 %.
Background. Classical nephroprotection reduces its effectiveness at the late CKD stages; the search for effective algorithms is hampered by accelerating decline in GFR, therefore there are no generally accepted ways to evaluate the effectiveness. Aim: to build a model for predicting the GFR decline rate in order to assess the effectiveness of the intensive follow-up. Methods. A representative group of regular follow-up (N=540) was allocated from the city database (N=7696) to built-up the polynomial model that predicts GFR annual decline. We used the model to evaluate the intensive monitoring effectiveness (N=100) by the difference between predicted and actual rates of GFR decline. We also selected well matched subgroup of 200 patients for direct comparison of hard and surrogate outcomes. Results. During last year before need in dialysis, the rate of GFR decline in intensive group was 5.981.69 vs. the predicted 9.060.59ml/min/1.73 m/year. We used that assessment of the intervention effectiveness as dependent variable in regression and categorical analysis. The significant components of the nephroprotection: phosphatemia decrease (0.25 mmol/l), hemoglobin increase (1 g/dl), effective administration of RAAS blockers (to reduce proteinuria by 0.1 g/l), systolic blood pressure decrease (5 mmHg), calcemia deviations decrease from the target (0.1 mmol/l), acidosis correction (2 mmol/l), inflammation reduction and albumin increase (1.5 g/l) -were associated with the smaller GFR decrease rate by 15%. In intensive group, the dialysis risk was 2.2 times lower, the death risk was 4 times. The only planned dialysis start was ensured in intensive group, 67% chose peritoneal dialysis. Conclusions. The prediction of GFR decline rate calculated by nonlinear model in comparison with the actual one can evaluate the nephroprotection effectiveness; it differs significantly from the classical ones at the CKD late stages.
Background. The current practice of patients with advanced CKD stages management is not optimal, as it leads to the risk of an emergency dialysis start with an unfavorable prognosis, does not utilize all the possibilities of nephroprotective therapy and does not provide optimal correction of the most important uremic syndromes before starting dialysis, which worsens the per spectives of long-term patient-oriented dialysis treatment. THE AIM. The obtained features of the standard practice will provide the possibility to assemble group carefully matched with intensive management group to compare outcomes in future prospective study and to assess the significance of the proposed program components of the intensive management of patients with advanced stages of chronic kidney disease in the "transition center". PATIENTS AND METHODS. A group with regular (at least 6 visits per year) follow-up of 540 patients with baseline CKD3B was retrospectively formed from the city nephrology center database (which included 7696 patients with CKD3 and higher) and was traced to the need for renal replacement therapy or to death. As part of the follow-up, patients underwent regular clinical and laboratory evaluation and received nephroprotective therapy, which were recorded in the database. RESULTS. The dynamics of an accelerating decrease in eGFR (according to CKD-EPICr) from median of -2.76 (-3.26÷-2.36) to -4.34 (-5.01÷-3.46) and further to -6.01 (-7.11÷-5.23) ml/min/1.73 m2/ year for the stages of CKD3B→CKD4→CKD5 in parallel with the dynamics of blood levels of hemoglobin (and iron), phosphate (and calcium), albumin, as well as proteinuria is described – factors that turned out to be significant in the multiple regression model with a dependent variable – the rate of eGFR reduction (the significance of the model F=2.864; p=0.015). CONCLUSION. The obtained detailed description of the progression of CKD in a typical regional population under standard management conditions will provide the possiblity to form a group from a cohort of regular monitoring in a nephrocenter, carefully compared with an intensive management group in the prototype of a transition center based on a large inpatient dialysis center to assess the significance of the components of the proposed control and interventions program.
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