Introduction: A wide range of oral hypoglycemic drugs with various mechanisms of effect are available for the treatment of patients with 2nd type diabetes mellitus today. Despite the high effectiveness of these agents in the normalization of glycemia, they cause different chronic complications in many patients with 2nd type diabetes mellitus. However, during the last years, a range of principal new data has been accumulated on the pleiotropic effects of the last classes of oral hypoglycemic agents -inhibitors of the 2nd type sodiumglucose cotransporter (SGLT2). Materials and Method:Three electronic databases were checked to find out studies reporting the data on the mechanisms and clinical significance of the nephroprotective effect of inhibitors of the sodium-glucose cotransporter of 2nd type (glyphlozines) in patients with 2 nd type diabetes mellitus. The primary outcome was to learn the worldwide tendency on this matter and to compare the results of different researchers. Results:We found 25 studies as eligible for our review. The review presents data on the mechanisms and clinical significance of the nephroprotective effect of inhibitors of the sodium-glucose cotransporter of 2nd type (glyphlozines). The effects associated with the influence of representatives of this pharmacological group on the glomerular filtration rate, glycemia, diuresis, ketogenesis and other factors are discussed. The results of recent experimental and clinical studies aimed at studying certain aspects of the nephroprotective effect of SGLT2 inhibitors in 2nd type diabetes mellitus and other pathological conditions were analyzed. Conclusion.SGLT2 inhibitors associate with a multicomponent nephroprotective effect, which confirmed by the results of both experimental and clinical studies. The nephroprotective potential of SGLT2 inhibitors is maximally realized in the presence of diabetes and remains not entirely clear in the case of another kidney pathology.
ATIN (20%) was the commonest histological diagnosis in NDKD, followed by IRGN and IgA nephropathy 20 and 17.77% respectively. Conclusions: Most common histopatholgical lesion in patients with diabetes with renal dysfunction is DN, but NDKD is not an uncommon diagnosis in diabetics. Duration of diabetes was less in NDKD patients ,those with NDKD belonged to a younger age group, sizable number of patients had retinopathy suggesting a low threshold for renal biopsy.ATIN was most common histological diagnosis followed by IRGN and IgA nephropathy; diseases requiring immune suppression including FSGS, MN, Crescentric GN were also seen.So this study highlights the importance of renal biopsy as various primary glomerulopathies will need specific treatment including immune suppression.
Background and Aims Chronic kidney disease (CKD) significantly alters the pharmacokinetics of drugs, which in practice complicates the selection of adequate anticoagulant therapy (ACT) in patients with atrial fibrillation (AF) and CKD. At the same time, in the vast majority of patients with AF and CKD, ACT is required to prevent life-threatening thromboembolic complications. In such an environment, maintaining a balance between the effectiveness and safety of ACTs is extremely important. Aim is evaluation of the efficacy and safety of the use of direct oral anticoagulants (OAC) in CKD stages 1-3 in combination with AF. Method The study included 93 patients (38 men and 55 women) aged 41 to 86 years with CKD stages 1-3 and AF receiving therapy with OAC (rivaroxaban) and vitamin K antagonists (warfarin). The observation period was 12 months. Results An analysis of 75 patients with CKD of various stages and AF receiving rivaroxaban was performed, the control group consisted of 18 patients taking warfarin. The average CHA2 DS2-VASc score in the OAC group was 4.1±1.8 points, in the warfarin group - 4.2±1.3 points. There were also no significant differences between the groups in terms of the average score on the HAS-BLED scale (risk of developing hemorrhagic complications): 2.3±0.94 points in the OAC group, 2.5±0.6 points in the warfarin group. Among the comorbidities in the OAC group, 93.2% of patients had arterial hypertension (AH), 24.5% had type 2 diabetes mellitus (DM); in the warfarin group, 94.3% of patients had hypertension and 16.8% had type 2 diabetes. In 23.9% of patients in the OAC group, minor bleeding was recorded. The largest number of hemorrhagic complications occurred in patients with stage 3 CKD: 18.9% of bleeding, which significantly (p<0.05) exceeds the number of bleeding in patients with a more pronounced decrease in renal function. In 33.3% of patients with diabetes, hemorrhagic complications were recorded, which is significantly (p<0.05) more than in the group of patients without diabetes - 21.4%. The greater number of hemorrhagic complications is most likely due to a more pronounced progression of the decline in renal function compared with patients without diabetes: 71.4% of patients with diabetes showed a decrease in GFR by an average of 16.6 ml/min/1.73 m2 for 12 months, which is significantly more (p<0.05) than in patients without diabetes (an average of 5.7 ml/min/1.73 m2). Conclusion In patients with CKD stages 1-3 with non-valvular AF, the use of OAC is most effective and safe in preventing thromboembolic complications. At the same time, the progression of CKD against the background of diabetes when taking anticoagulants occurs faster than in its absence, regardless of the specific anticoagulant. Patients with AF, DM and CKD are more likely to have hemorrhagic complications, which requires more frequent monitoring and monitoring of the functional state of the kidneys.
Background and Aims Patients with chronic kidney disease (CKD) develop bleeding and thromboembolic tendencies, so the indication for the use of anticoagulants for atrial fibrillation (AF) is difficult. AF is the most common chronic cardiac arrhythmia, and thromboembolism and ischemic stroke in particular are the main complications. In recent years, new oral anticoagulants (rivaroxaban) have been developed and have shown superiority over classic anti-vitamin K anticoagulants in preventing the risk of stroke, systemic embolism and bleeding. Aim is to evaluate the safety parameters of rivaroxaban in patients with stage 4 chronic kidney disease (CKD) or a transient sustained decrease in glomerular filtration rate (GFR) to 15–29 ml/min/1,73 m2 in the presence of atrial fibrillation (AF). Method Multicenter prospective randomized study that included patients from cardiology departments in 2019. Of 5448 hospitalized patients, 109 (2%) patients with AF and CKD stage 4 or a sustained decrease in GFR to 15-29 ml/min/1.73 m2 were randomized in a 2:1 ratio to rivaroxaban 15 mg/day (n=73) or warfarin (n=36). Primary endpoint: development of large, small and small clinically significant bleeding according to the BARC (Bleeding Academic Research Consortium) and ISTH (International Society on Thrombosis and Hemostasis) scales. The average follow-up period is 12 months. Results Patients taking warfarin were significantly more likely to develop minor bleeding according to BARC scales (n=26 (72.2%) versus n=31 (42.4%), p<0.01) and ISTH (n=22 (61.1%) versus n=27 (36.9%), p<0.01) and all clinically significant (minor clinically significant and major) bleeding according to the ISTH scale [n=10 (27.7%) versus n=8 (10.9%), p=0.03]. The number of readmissions was 32 (43.8% of patients) in the rivaroxaban group, 17 (47.2% of patients) in the warfarin group (p=0.57), of which 12 (37.5%) and 7 (41.1%) (in the rivaroxaban and warfarin groups, respectively) - for urgent reasons (p=0.96). A significant improvement in the dynamics of creatinine levels, GFR (according to CKD-EPI) in the rivaroxaban group was revealed. Conclusion The study provides evidence of a favorable safety profile for rivaroxaban compared with warfarin in patients with AF and advanced CKD.
Background and Aims The assessment of the thromboembolic risk (TE) and transient ischemic attacks (TIA) in patients with chronic kidney disease (CKD) in combination with atrial fibrillation (AF) and the effect of complex treatment, including rivoraxaban. Method The study included 28 patients, 16 men and 12 women, average age - 57.8 ± 6.9 years. Patients with 3rd stage CKD (GFR 30-50 ml/min) associated with various forms of non-valve AF were examined. All patients were at high risk according to the classification of stroke risk stratification. The risk of thromboembolic complications was assessed using the CHA2DS2-VASc scale. Depending on the form of AF, patients with CKD were divided into 2 groups: with paroxysmal AF and CKD (n = 9) and persistent AF and CKD (n = 19). The average age in the 2 groups was 52.7 ± 6.4 and 58.4 ± 7.4 years, respectively. A history of 11 patients (39.3%) had ischemic stroke and TIA. All patients underwent echocardiography and transesophageal echocardiography (TE EchoCG). The peak blood flow velocity was a quantitative reflection of the hemodynamic state of left atrium (LA). Hemoglobin, creatinine, eGFR (CKD-EPI) and coagulogram were also monitored. Results According to the results of TE echocardiography, the size of the LA in patients with stage 3 CKD and paroxysmal AF is less than in the group of persistent AF (43.7±2.8 mm and 48.6±5.8 mm, respectively, p<0.05). The average value of the peak blood flow velocity was reduced in all patients - 34.88±10.59 cm/sec, in the presence of thrombosis this parameter significantly decreased - 24.3±2.49 cm/sec (p<0.001). Atrial thrombi were detected in 10 patients (35.7%). Spontaneous echocardiographic contrast (SEC) was found in 7 people (25%). We found that in patients with a thrombus in the auricle of the LA ejection fraction (EF) was significantly lower than in patients without thrombi. The average score on the CHA2DS2-VASС scale was 5. A higher incidence of a thrombus in the auricle of the LA was revealed in patients with persistent AF than paroxysmal AF (7 and 3, respectively). Only 15 patients (53.6%) received oral anticoagulants (OAC) on an outpatient basis, and 2 (7.1%) took aspirin. In the hospital, everyone was prescribed rivoraxaban in a dose of 15 mg once a day. After 4 weeks of treatment with rivoraxaban, from 7 patients with a revealed SEC during repeated TE echocardiography, the disappearance of SEC was observed in 4 patients (57%). In 6 patients (60%) was revealed thrombus lysis in the LA. In 16 (57.1%) patients was noted an increase in GFR above 50 ml/min. Coagulogram values in all patients throughout the observation were within normal limits. Conclusion TE echocardiography allows to distinguish among patients with stage 3 CKD and AF group with a high risk of stroke and TIA. The use of rivoraxaban for 4 weeks allows lysis of blood clots in the auricle of the LA in 60% of patients, and the disappearance of the SEC effect in 57% of cases. This allows us to recommend rivoraxaban for the treatment of patients with AF, especially with a high risk of thromboembolic complications.
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