Background. The relationship between obstructive sleep apnea (OSA) and hypertension (AH) is well known. In numerous studies it was found that obstructive sleep apnea was an independent predictor of the development of resistant AH (RAH), and the severity of apnea was directly correlated with the severity of RAH with the exception of the such confounders as age, obesity, sex.

The purpose of this publication is to present a new strategy and modern approaches of drug and non-drug therapy of resistant hypertension in patients with OAS with the possibility of their implementation in real clinical practice.

Conclusion. Currently, for a practitioner, the therapy of the patient with OSA and RAH is a serious clinical problem. A new rational therapeutic strategy for the treatment of such patients includes a combination of three-component drug therapy and non-drug continuous positive air pressure therapy (CPAP therapy). A reasonable duration of CPAP therapy should exceed 12 weeks. The proposed strategy for the treatment of patients with OAS+RAH has the highest efficiency of achieving blood pressure levels and significantly reduces the risks of fatal cardiovascular events.

Cardiorenal syndrome in patients with heart failure is a regular link in the chain of cardiorenal continuum. Physicians of various specialties may encounter patients with cardiorenal syndrome: general practitioners, cardiologists, nephrologists, resuscitators, anesthetists, cardiac surgeons, etc. The currently definition, classification, pathogenesis, diagnosis and epidemiology of cardiorenal syndrome in patients with heart failure were presented in first part of our review. In the second part, prognosis, approaches to the prevention and treatment of cardiorenal syndrome in patients with heart failure are discussed. They include the treatment of cardiovascular pathology and heart failure in accordance with current guidelines for the prevention of episodes of acute and decompensated chronic heart failure; diet; smoking cessation, alcohol, nephrotoxic substances; body weight, blood pressure and glycemia control; angiotensin converting enzyme inhibitors, angiotensin receptor antagonists or angiotensin receptors and neprilisin inhibitors (ARNI), statins; reducing of the abdominal pressure and others. It is necessary to develop and introduce new approaches to nephroprotection in patients with cardiorenal syndrome, which is possible with the joint work of a multidisciplinary team.

The review of literature presents modern ideas about the role of aldosterone in the development and maintenance of atrial fibrillation. It is shown that hormone takes part in all stages of the electrophysiological and structural atrial remodeling, contributing to the formation of the arrhythmia substrate. It was noted that adverse effects of the aldosterone in the myocardium are realized not only due to its high systemic production but also because of its direct synthesis in the atrial tissues. Increased expression of mineralocorticoid receptors in cardiomyocytes also play important role in the development of atrial fibrillation. It is demonstrated that hyperaldosteronemia can be a cause as well as effect of atrial fibrillation. The episode of arrhythmia is characterized by neurohormonal activation, increased intramyocardial aldosterone synthesis and high mineralocorticoid receptors expression. This contributes to the further progression of atrial remodeling and makes conditions for the arrhythmia recurrences.

Chronic obstructive pulmonary disease (COPD), along with cardiovascular disease, belongs to the leading chronic non-infectious diseases of our time, which, occurring in comorbidity, lead to the development of severe mutually aggravating complications.

Objective: to determine the methods of diagnosis and prevention of coronary accidents in patients with COPD living in the northern latitudes, based on the dynamic assessment of the parameters of respiratory function.

Materials and methods. The study was a holding during the five years extended instrumental examination (bodypletizmography methods, echocardiography) 182 patients with COPD (mean age of 65,0±1,2 years). Coronary events during prospective followup were recorded in 66 patients (mean age 65,0±1,2 years). Coronary events during prospective follow-up were recorded in 66 patients (mean age 65,0±1,2 years).

Results: in a cohort of 976 patients with COPD, the number of patients with moderate severity (54%) was 6 times higher than the number of patients with extremely severe bronchial obstruction (8,6%) (p <0,001). During the five-year period in patients with isolated COPD (n=116) progression of violations of volume and speed indicators of external respiration function was registered. It should be noted that the course of COPD in this sample of patients was associated with a predominant decrease in restrictive indicators, manifested in the form of a decrease in the reserve volume of exhalation (RVE) by 20,6% (p=0,004) in patients with COPD, constituting a risk group for the development of coronary catastrophes, there was no significant dynamics of parameters of respiratory function for five years (p >0,05). Patients with lower values of volume parameters of external respiration function, such as RVE, inhalation capacity (IC), during the five-year follow-up period had a recorded coronary event (p <0,05). The greatest number of coronary accidents among patients with COPD of moderate and high risk was recorded in the first 3 years of follow — up, among patients of very high risk-evenly over 5 years. Coronary catastrophes were associated with periods of exacerbation of the underlying disease (p <0,05). Their frequency (myocardial infarction, angina, coronary death) for five years in patients with COPD with very high, high and moderate coronary risk was 33,9%, 10,5%, 1,52%, respectively. Using stepwise discriminant analysis, it was found that the leading prognostic markers of coronary accidents in patients with COPD living in the Northern latitudes, are the data of echocardiography (end-diastolic dimensions of the left ventricle, systolic pulmonary artery pressure) and bodypletizmography methods (RVE).

Conclusion. It is recommended that the bodypletizmography methods and echocardiographic study all patients with COPD as binding studies to identify latent leaky restrictive disorders of function of external respiration with the first stage of the disease. Given the low level of diagnosis of COPD in Russia, a long asymptomatic course of the disease, the development of COPD after 10 years of living in the North, according to the literature, it is recommended to conduct an annual bodypletizmography as a screening method of examination of all smokers living in the Northern latitudes. Thus, the use of bodypletizmography with a targeted assessment of volume parameters, as well as echocardiographic studies, allows to identify groups at risk of coronary accidents and, thereby, to carry out timely prevention of the latter among patients with COPD.

Improving the nephrology service and increasing the availability of hemodialysis create the prerequisites for a deeper analysis of the associated complications and associated diseases. One of the main clinical conditions that worsen the patient’s prognosis is protein-energy deficiency (BPH), which is manifested by loss of muscle mass, strength and performance of skeletal muscles, which also leads to a decrease in quality of life, and often to disability and death.

The aim: assess of the relationship between myostatin and protein kinase β, as markers of the catabolic cascade, with the manifestations of PEW in hemodialysis patients.

Materials and methods: 80 people took part in the study (47 men and 33 women), the median age was 51.7 ± 11.6 years. All patients had CKD 5D stages with chronic hemodialysis treatment for an average duration of 33.5 (0.5; 236) months. All patients were carried out a detailed clinical and anamnestic examination, we estimated the anthropometric measurement, muscular strength were using the hand dynamometry method. The levels of MSTN and AKT were determined in serum by enzyme immunoassay (ELISA Kit, USA). Statistical analysis was carried out using STATISTICA 10.0 (StatSoft Inc., USA) and Microsoft Office Excel 2010 (Microsoft Corp., USA).

Results: A dependence of the local increase in skin folds with an increase in the MSTN level, as well as a decrease in the thickness of the subcutaneous fatty tissue with a decrease in AKT (p = 0.03) was detected. We proposed a muscle catabolism index for assessing the degree of muscle degradation. IT had a statistically proven association with degree PEW and clinical manifestations of it. Analysis of the effects of markers of systemic inflammation with MSTN did not give statistically significant results. However, in the subgroup with elevated AKT with the activation of anabolic processes, we observed a decrease in β2-microglobulin and an increase in serum iron (p = 0.04). In the subgroup with a high level of MSTN, higher concentrations of parathyroid hormone (PTH) were determined. We found a direct correlation between the increase in protein kinase β and the annual PTH fluctuation (r = 0.83, p = 0.01).

Conclusion. In our study, we were found that in patients with CKD5D receiving therapy with chronic hemodialysis, the activity of myostatin and protein kinase β varies. This leads to an increase in protein degradation over the processes of synthesis, which creates prerequisites for the development of sarcopenia. Taking into account the data obtained, further study of the intermolecular interactions of these markers in the catabolic cascade of muscle proteins is of research interest.

The aim of the reserch was to study the state of the cardiovascular system, systemic inflammation and balance oxidant/|antioxidant in patients with relapsing-remitting multiple sclerosis.

Material and methods. The study included 45 patients with relapsing-remitting multiple sclerosis (17 men and 28 women), age 28 [24; 32] years, disease duration 5.5 [2; 7] years. The control group included practically healthy patients, age 30 [25; 33] years. Patients with multiple sclerosis were examined neurologically with Expanded Disability Disease Score rating of disability. Instrumental methods included a comprehensive assessment of the cardiovascular system (24-hour Holter ECG monitoring and 24-hour blood pressure monitoring with determination of the daily arterial vascular stiffness, echocardiography). Laboratory methods included clinical and biochemical analysis of blood, lipid profile, glycemia, C-reactive protein. The indices of oxidative stress (acylhydroperoxide) and antioxidant protection (glutathione peroxidase, superoxide dismutase) were studied; a marker of endothelial dysfunction (vascular cellular adhesion molecule-1) were researched.

Results. In the group of patients with multiple sclerosis, there was an increase in C-reactive protein, the marker of endothelial dysfunction compared with the control group (p<0.001). The indicators of oxidative stress and antioxidant protection were statistically significantly increased (p<0.001). According to the results of Daily Blood Pressure Monitoring the variability of systolic blood pressure and diastolic blood pressure during daytime hours was reduced comparison to the control group (р<0,026) and (p<0.002) respectively. The indicators of daily arterial stiffness in the group of patients with multiple sclerosis was statistically significantly increased (p<0.001). According to the results of Holter ECG monitoring, no heart rhythm disorder was detected in both groups. In the group of patients with remitting course of multiple sclerosis, an increase in the number of supraventricular extrasystoles was detected compared with the control group (p<0.005). The main indicators of echocardiography were within normal values, no significant differences between the groups were found.

Conclusion. The study showed that multiple sclerosis patients are at risk of developing cardiovascular diseases and require increased attention to prevent the development.

Retroperitoneal fibrosis (Ormond’s disease) is a nonspecific inflammatory process in the retroperitoneal tissue with the formation of fibrous tissue that causes compression of the ureter and other adjacent structures. This is a rare disease, its frequency is about 1 case per 200 thousand people. This explains his little scrutiny, the absence of a real standard of patient management with the determination of the nature of drug therapy and the most effective method of surgical treatment. The prognosis is determined by the activity of the disease with the development of urinary tract obstruction and the occurrence of renal failure and other complications. The article presents a clinical observation of a 40-year-old patient suffering from Ormond’s disease. In this case, the initial treatment to remove retroperitoneal fibrosis was undertaken by surgeons 5 months after the onset of the first symptoms of the disease. Drug therapy was started 10 months later, when the final diagnosis was made using immunohistochemistry and the progression of the disease became apparent (by increasing the amount of retroperitoneal fibrosis). On the background of immunosuppressive therapy, a decrease of the severity of retroperitoneal fibrosis was noted, however, it was not possible to achieve the full effect, most likely due to the late start of treatment and the irreversible fibrosis formed in this connection. Treatment was also hampered by the persistently recurring urinary tract infection. The best method of treatment in this situation (with persistent obstruction of the ureter and the threat of renal damage) can only be surgical treatment aimed at restoring adequate urodynamics. Based on the presented clinical observation, we can make the following conclusions: Ormond's disease (retroperitoneal fibrosis) needs further study and development of standards for the management of patients with this pathology; immunosuppressive therapy should be prescribed as soon as possible, which can prevent the development of irreversible fibrosis; With advanced stages of the disease, treatment should be comprehensive, including both remedies and surgical intervention.

In article we present particular qualities of disease pattern and methods of treatment in patients with ulcer colitis associated with primary sclerosing cholangitis and autoimmune hepatitis. Course of disease was complicated by bacterial cholangitis, sepsis, multiple organ failure. There are described pathogenetic features of autoimmune livers and bowel illness. It was shown the role of bacterial translocation of microbes. There are described about differential diagnostic of primary and secondary cholangitis. Features of curing the patients are reminded in critical conditions are reviewed in article. There sketched role of glucocorticosteroids in critical care. Modern guidelines for the management the patients with overlap syndrome are highlighted. Patient D. was admitted to hospital in intensive care unit. There disease patterns of collapse, systemic inflammation response syndrome. The examination was established exacerbation of ulcer colitis complicated inflectional morbidity with sclerosing cholangitis and autoimmune hepatitis. This condition led to sepsis and multiple organ failure. Instead of intensive care there was a progressive deterioration until near death experience. Resuscitation procedure within 6 minutes were successful. Multiple areas of necrosis have developed on the limbs because of multiple organ failure and intensive vasopressors therapy. Glucocorticosteroids were prescribed in combination with antibacterial drugs were assigned because of ulcerative colitis’s exacerbation and cytolysis, regardless sepsis. On the thirtieth day of stay in hospital, the patient D. was transferred from the intensive care unit to the gastroenterology department, where the treatment was continued. Because of the cure signs of multiple organ failure, infectious complications, exacerbation of ulcerative colitis and primary sclerosing cholangitis were regressed. We supervise of patient.

The article is devoted to the problem of panhypopituitarism, the diagnosis of which presents certain difficulties in connection with the combined lesion of several peripheral endocrine glands. Modern classification, etiopathogenesis, diagnosis and treatment of the disease are presented. Acquired hypopituitarism in adults develops, as a rule, at the age of 30-60 years, mostly women are affected. Pangypopituitarism is diagnosed when all pituitary tropic functions are affected, which is observed in case of damage to 90% of the adenohypophysis cells. The variety of clinical manifestations of the disease is determined by the different effects of pituitary hormones and the degree of their deficiency. The diagnosis is based on a history of etiological factors causing damage to the pituitary gland, and clinical signs of insufficiency of peripheral endocrine organs, which is confirmed by the results of laboratory studies. In hypopituitarism due to, for example, the growth of pituitary adenoma, the clinical picture develops gradually, and the disorder of the secretion of the pituitary tropic hormones usually occurs in the following sequence: the production of somatotropic hormone, gonadotropins, then thyrotropic hormone, adrenocorticotropic and, lastly, prolactin decreases. Neurosurgery or hemorrhage in the pituitary gland causes a rapid manifestation of the disease, and the severity of the condition is associated mainly with adrenal insufficiency. In the case of surgery for pituitary adenoma, there is a recommendation to determine morning blood cortisol on the 3rd day after surgery. Conservative treatment is aimed at compensating for hormone deficiency. According to the clinical significance of endocrine disorders, their correction is carried out in the following sequence — first, compensation for adrenal insufficiency, then thyroid, sex glands and somatotropin. In case of damage to the posterior lobe of the pituitary gland with the development of diabetes insipidus syndrome, replacement therapy for vasopressin deficiency is also required. The clinical example presented in the article reflects the difficulty of diagnosing and interpreting the data of hormonal studies in panhypopituitarism. An analysis of the described clinical situation shows the importance of understanding the pathogenesis of the disease when conducting a diagnostic search. Adequate replacement therapy can restore normal well-being in patients with hypopituitarism.