Журнал для непрерывного медицинского образования врачей COVID-19 у больных, получающих лечение программным гемодиализом ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯ 1 Государственное бюджетное учреждение здравоохранения города Москвы «Городская клиническая больница № 52 Департамента здравоохранения города Москвы», 123182, г. Москва, Российская Федерация 2 Федеральное бюджетное учреждение науки «Московский научноисследовательский институт эпидемиологии и микробиологии им. Г.Н. Габричевского» Федеральной службы по надзору в сфере защиты прав потребителей и благополучия человека, 125212, г. Москва, Российская Федерация 3 Филиал федерального государственного бюджетного военного образовательного учреждения высшего образования «Военно-медицинская академия имени С.М. Кирова» Министерства обороны Российской Федерации, 107392, г. Москва, Российская Федерация 4 Федеральное государственное бюджетное образовательное учреждение высшего образования «Московский государственный медикостоматологический университет имени А.И. Евдокимова» Министерства здравоохранения Российской Федерации, 127473, г. Москва, Российская Федерация 5 Федеральное государственное бюджетное учреждение «Главный военный клинический госпиталь им. Н.Н. Бурденко» Министерства обороны Российской Федерации, 105229, г. Москва, Российская Федерация
Background and Aims Presently, the dilemma of what to do with a functioning arterio-venous fistula (AVF) in post-kidney transplantation patients is a subject of debate. One of the arguments in favor of AVF closure is symptomatic congestive heart failure (CHF) due to AVF-induced cardiomyopathy. The subject of the study was the evaluation of the dynamics of some morpho-functional cardiac parameters in post-kidney transplantation patients with AVF-induced CHF before and after AVF closure. Method The results of prospective single center study are presented. 13 post transplantation patients with severe AVF-induced CHF (III-IV f.c. NYHA) were enrolled. Echocardiography (Echo), Doppler evaluation of AVF flow (Qa) and calculation of cardiopulmonary recirculation (Qa/CO) were performed simultaneously (split-protocol) at baseline together with estimation of creatinine plasma level. All patients underwent surgical closure of AVF. In 8 weeks after the closure, an assessment of CHF, Echo and creatinine plasma level were carried out in all enrolled patients. Statistical analysis was performed using the STATISTICA 13 software (T-test). Results The average age – 44 ±13 y, males 54%. All patients bore an upper arm proximal AVF. The average flow of AVF (Qa) – 3.4 ±1.4 L/min, average Qa/CO – 49 ±15%, Qa/CO was more than 30% in 92% of patients. The median of AVF vintage was 5 y (IR 3;10). In 8 weeks after AVF closure, complete clinical resolution of CHF, reduction of volumetric heart parameters, decrease of sPAP, improvement of diastolic function were observed. There was no significant difference in the serum creatinine value (1.85 ±0.66 mg/dL vs 1.97 ±0.95 mg/dL, p >0.05). The results of Echo data before and after AVF closure are presented in Table 1. Conclusion The surgical closure oh high flow AVF in post-kidney transplantation patients with AVF-induced CHF was resulted in significant improvement of morpho-functional cardiac parameters. The CHF due to AVF-induced cardiomyopathy should be considered as one of the indications to AVF closure in post-kidney transplantation patients. CO, cardiac output; CI, cardiac index; LV EDVi, left ventricular end-diastolic volume index; LV ESVi, left ventricular end-systolic volume index; LAVi, left atrial volume index; RAVi, right atrial volume index; TAPSE, tricuspid annular plane systolic excursion LVMi, left ventricular mass index; sPAP, systolic pulmonary arterial pressure; LVEF, left ventricular ejection fraction; Е/A ratio, E - peak early mitral inflow wave velocity, A - peak late mitral inflow wave velocity.
Background. Present concepts of the novel coronavirus infection prognosis in haemodialysis (HD) patients are rather controversial. There is little information on therapy efficiency and safety in such patients. We studied COVID-19 course specifics, prognostic factors associated with fatal outcomes, therapy efficiency and its transformation at different stages of the pandemic first year. Materials and methods. Single-centre retrospective uncontrolled study included 653 COVID-19 HD-patients treated at Moscow City Nephrology Centre from April 1 to December 31, 2020. Results. This period mortality rate was 21.0%. Independent predictors of COVID-19 unfavourable outcome in HD patients were pulmonary lesion extension (CT grades 34), high comorbidity index, and mechanical ventilation. Approaches to COVID-19 treatment modified significantly at different periods. Immunomodulatory drugs (monoclonal antibodies to IL-6, corticosteroids) were used largely at later stages. With tocilizumab administration, mortality was 15.1%, tocilizumab together with dexamethasone 13.3%; without them 37.8% (р0,001). Tocilizumab administration in the first 3 days after hospitalization of patients with CT grades 12 was associated with more favourable outcomes: 1 out of 29 died vs 6 out of 20 (tocilizumab administered at later periods); p0.04. There was no significant difference in death frequency in patients with CT grades 34 depending on tocilizumab administration time. Conclusion. COVID-19 in HD patients can manifest in a severe course with unfavourable outcome. It is urgent to identify reliable disease outcome predictors and develop efficient treatment in this population.
Acute myocardial dysfunction (AMD) remains prominent among extrapulmonary manifestations of COVID-19. Takotsubo syndrome (TS) is one of the causes of AMD development. TS incidence in patients with COVID-19 is currently unknown. The report presents a clinical case of an elderly female patient on maintenance hemodialysis with severe COVID-19. During the session of therapeutic plasma exchange (TPE), the patient had an episode of ventricular fibrillation followed by cardiogenic shock development and ECG changes, similar to myocardial infarction. Echocardiographic (Echo) data showed a distinctive pattern of biventricular TS with a significant systolic function decrease in both ventricles. Emergency CT angiography ruled out obstructive lesions of coronary arteries. Full recovery of both ventricles systolic function, regression of ECG changes, and complete resolution of cardiogenic shock were observed within the next week. The subsequent course of the disease was complicated by sepsis and multiple organ failure which determined the lethal outcome.The autopsy findings excluded coronarogenic and viral myocardial damage. The presented case demonstrates a life-threatening TS pattern in patients with severe COVID-19. TPE procedure should be treated as a possible trigger of TS.
Background and Aims Pulmonary hypertension (PH) is prevalent in patients with functioning high-flow arterio-venous fistula (HFAVF) and associated with congestive heart failure (CHF). The real incidence and possible causes of this phenomenon is a matter of debate. Hemodynamic effects of HFAVF is considering as one of the reasons for PH formation. The subject of study was the impact of HFAVF on selected parameters of central hemodynamics. In particular, the diagnostic relevance of test of temporary HFAVF occlusion (TTO) was evaluated during right heart catheterization (RHC). Method A total of 13 patients were enrolled: 8 - after kidney transplantation (KT) with preserved allograft function and 5 - on maintenance hemodialysis (HD). All of them demonstrated clinical presentation of CHF III-IV class (NYHA). Severe PH and diastolic disfunction (DD) were observed at a baseline: echocardiographic systolic pulmonary arterial pressure sPAP (mmHg): M=59 (SD 13), ratio of mitral early diastolic inflow velocity (E) (pulsed wave Doppler) to average of septal and lateral mitral annular early-diastolic peak velocity (e′) (tissue Doppler imaging) E/e′ M=18 (SD 5). The ones who have comorbid conditions that cause PH were excluded. All patients bore an upper arm HFAVF, flow of the AVF (Qa) measured by Doppler ultrasonography was markedly high (Qa): M = 3,8 l/min (SD 1,2), the cardio-pulmonary recirculation (Qa/CO): M = 51% (SD 13). All patients underwent RHC and TTO AVF. Echocardiography (Echo) was performed initially and on the follow up (8 weeks after AVF closure/flow reduction). Statistical analysis was performed using the STATISTICA 13 software (Wilcoxon, T-test). Results The results of RHC and Echo data are presented in tables 1, 2. As can be seen from the table data, all cases demonstrated instrumental features of high output CHF (HO CHF) in accordance with patient’s clinical status. TTO of HFAVF resulted in statistically significant decrease in CO and CI values, but no changes in PAP parameters were observed. Taking into account clinical and instrumental features of advanced CHF, HF AVF was closed in 8 patients after KT and in 2 patients on HD. 3 patients on HD underwent AVF flow reduction up to Qa not exceeding 1,1 l/min. Follow-up demonstrated complete resolution of CHF and dramatic improvement of DD, reduction in CO, CI, sPAP, volume parameters. CO, cardiac output; CI, cardiac index; sPAP, systolic pulmonary arterial pressure; meanPAP, mean pulmonary arterial pressure; RAP, mean right atrial pressure; PCWP, pulmonary capillary wedge pressure; LV EDVi, left ventricular end-diastolic volume index; LAVi, left atrial volume index; RAVi, right atrial volume index; Conclusion PH is a component of AVF-induced HO CHF and could be classified as postcapillary one. TTO confirms significant HFAVF contribution to specific changes of parameters of central hemodynamics due to HO CHF. TTO does not impact on PAP values and therefore is not valid to clarify PH genesis per se.
1 ФГБОУ ВО «Российский национальный исследовательский медицинский университет имени Н.И. Пирогова» Минздрава России, Москва, Российская Федерация 2 ФГБУ «Федеральный научный центр трансплантологии и искусственных органов имени академика В.И. Шумакова» Минздрава России, Москва, Российская Федерация 3 ФГБОУ ВО «Московский государственный медико-стоматологический университет имени А.И. Евдокимова», Москва, Российская Федерация 4 ГБУЗ «Городская клиническая больница № 52 Департамента здравоохранения г. Москвы», Москва, Российская Федерация Представлено описание клинического случая обратимой высокой легочной гипертензии (ЛГ) у паци ентки с успешной трансплантацией почки (ТП), особенностью которого было функционирование ар териовенозной фистулы (АВФ) с избыточным кровотоком в течение 15 лет при отсутствии показаний к проведению гемодиализа. ЛГ сопровождалась развитием тяжелой застойной сердечной недостаточности (ЗСН) с высоким сердечным выбросом. Лигирование АВФ привело к полному регрессу клиникоинс трументальных и лабораторных признаков ЛГ и ЗСН в течение 2 недель. Обсуждается патогенетическая роль избыточного кровотока по АВФ в формировании ЛГ и ЗСН. Рекомендуется лигирование АВФ с избыточным кровотоком в случае формирования симптомной ЛГ у пациентов после успешной ТП.Ключевые слова: легочная гипертензия, сердечная недостаточность, лигирование артериовенозной фистулы, трансплантация почки.
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