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: Patients with Type 2 Diabetes (T2DM) and patients on maintenance hemodialysis (MHD) are at a high risk of adverse clinical course of COVID-19. To date, the causes of high mortality in these groups are not fully understood. Data about peculiarity of clinical course and Tocilizumab (TCZ) administration in patients with T2DM receiving MHD due to outcome of diabetic kidney disease (DKD) are not yet highlighted in current publications.AIMS: Identification of risk factors (RF) of adverse COVID-19 outcome and evaluation of TCZ administration in patients with T2DM receiving MHD due to DKD.MATERIALS AND METHODS: The patients treated in Moscow City Hospital No52 were included in retrospective observational study. The observation period was from 04.15 to 07.30 2020. The study endpoints were the outcomes of hospitalization — discharge or lethal outcome. Data were collected from electronic medical database. The following independent variables were analysed: gender, age, body mass index, time from the onset of symptoms to hospital admission, cardiovascular and general comorbidity (Charlson Index, CCI), cardiovascular event (CVE) during hospitalization, treatment in ICU, mechanical ventilation (MV), degree of lung damage according to CT data, level of prandial glycemia at admission, MHDassociated parameters (vintage, type of vascular access, frequency of complications). The autopsy reports were evaluated for the purpose of lethal structure investigation. In a subgroup treated TCZ the time from symptoms onset to TCZ administration and number of laboratory indicators were evaluated.RESULTS: 53 patients were included, mean age 68 ±9 y, males — 49%. General mortality in observation cohort was 45%, mortality in ICU — 81%, mortality on MV — 95%. High cardiovascular and general comorbidity was revealed (mean CCI — 8,3 ±1,5 points). The causes of outcomes according to autopsy reports data: CVE 37,5% (among them — acute myocardial infarction during hospitalization), severe respiratory failure — 62,5%. The independent predictors of lethal outcome were: MV (OR 106; 95% CI 11,5–984; р <0,001), 3-4 degree of lung damage according to CT data (ОR 6,2; 95% CI 1,803–21,449; р = 0,005), CVE during hospitalization (ОR 18,9; 95% CI 3,631–98,383; р <0,001); CCI ≥10 points (ОR 4,33; 95% CI 1,001–18,767; р = 0,043), level of prandial glycemia at admission ≥10 mmol/l (ОR 10,4; 95% CI 2,726–39,802; р <0,001). For risk identification of upcoming lethal outcome a predictive model was created with the use of discovered RF as variables. The predictive value of this model is 92,45% (positive prognostic value — 96,5%, negative prognostic value — 87,5%).In TCZ treated subgroup the laboratory markers of adverse outcome were detected with application of correlation analysis. Among them: increasing level of CPR 24-48 hours before lethal outcome (r = 0,82), the reduction of lymphocytes count after TCZ administration (r = -0,49), increasing of leukocytes and further reduction of lymphocytes count 24-48 hours before lethal outcome (r = 0,55 и r = -0,52, resp.)).CONCLUSIONS: The number of RF of adverse COVID-19 outcome in patients with T2DM receiving MHD due to DKD are identified. CVE is one of the leading causes of mortality in study cohort. According to our experience the preventive (instead of rescue) strategy of TCZ administration should be used.

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 &gt;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.