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AIM: To study clinical and morphological variants and frequency of renal involvement in patients with rheumatoid arthritis (RA). MATERIAL AND METHODS: Routine laboratory tests, device (urography, dynamic scintigraphy of the kidneys) and ultrasound investigations, lifetime and postmortem examinations of renal tissue using histological, immunohistochemical and electron-microscopic techniques, biopsy of gingival and rectal mucosa for amyloid detected renal lesions in 268 (46.2%) of RA patients followed up for 25 years meeting the ARA criteria. In 98 (37%) patients renal lesions were verified morphologically. Lifetime renal biopsies were made for 60 of them. RESULTS: The diagnosis of chronic pyelonephritis was made in 117 patients, 42 patients had nephrolithlasis, nephroptosis and papillary necrosis were found in 49 and 3 patients, respectively. Arterial hypertension was present in 96 examinees, nephrotic syndrome was diagnosed in 19 and chronic renal failure--in 67 patients. Drug-related nephropathy occurred in 35 cases, in 26 cases symptoms of pyelonephritis arose prior to RA. Combination of renal diseases was found in 197 patients. Renal pathology was not verified morphologically only in 5 cases. Glomerulonephritis (GN) variants were present in 35 patients: mesangioproliferative (n = 27), membraneous (n = 5), mesangiocapillary (n = 3). 12 of them took Au preparations or D-penicillamin, therefore diagnosis of true rheumatoid GN was feasible only in 23 of them. GN was combined with renal amyloidosis (n = 28), minimal morphological changes (n = 19), interstitial/tubulointerstitial nephritis (n = 4), pyelonephritis (n = 4), arteriolosclerotic nephrosclerosis (n = 3). 41 patients with diagnosed pyelonephritis were found morphologically to have amyloidosis (n = 16), GN (n = 10), minimal morphological changes of renal tissue (n = 6), tubulointerstitial nephritis (n = 3), pyelonephritis, pyelonephritis alone (n = 4). CONCLUSION: The above morphological findings point to high occurrence of renal pathology in RA. In many cases morphological signs are more serious than clinical symptoms. If RA activity is not controlled, nephritis of any type may transform into amyloidosis. When it is impossible to formulate morphological diagnosis in RA patients, it is proposed to use the term "nephropathy". Unrelated to RA nephropathy's diagnosis is valid in cases when renal pathology manifested before RA. Renal diseases arising in the presence of RA may be associated with this disease and should be reflected in its classification.

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15 patients with Still's disease of adults (SDA) were followed up for 17 years maximum. The disease showed a principal clinical-laboratory syndrome observed both in SDA debut and exacerbations (recurrences). Clinical manifestations of SDA do not arise stereotypically causing difficulties in its nosological interpretation. SDA course is represented by three variants: monophasic (monocyclic), recurrent and chronic persisting with development of destructive arthritis. Use of nonsteroid antiinflammatory drugs is analysed, indications to administration of glucocorticoids and basic treatment are listed. Reversibility of systemic SDA manifestations except the articular one is shown. About half of the patients develop chronic destructive arthritis. In active SDA, renal amyloidosis and chronic renal failure may develop with lethal outcome.

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183 patients with rheumatoid arthritis (RA) received basic drugs for 3 to 15 years. The patients were followed up for 13.5 years, on the average, with intervals 6-48 months. Clinical, laboratory, instrumental and morphological methods of investigation were used. The findings are reviewed on the mortality and causes of death, lethal tumors, overall complications and those observed in 55 patients on glucocorticoids.

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A prospective study was conducted of basic antirheumatic drugs (chrisanolum, myocrisin, ridaura, chlorbutin, D-penicillamine) versus nonspecific antiinflammatory treatment in 127 patients with rheumatoid arthritis (RA). The drugs were compared by their effect on myocarditis. Basic antirheumatic drugs were found much superior to nonsteroid antiinflammatory drugs. The highest response was registered for chrisanolum myocrisin and chlorbutin after 6-12 month continuous treatment. Warning: chrisanolum, myocrisin and ridaura may produce unwanted short-term effects on left ventricular contractility in developing extracardiac complications of aurotherapy.

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The analysis of life-time diagnosis of valvular heart disease in rheumatoid arthritis (RA) patients has been made basing on a long-term clinico-echocardiographic investigation. Within 18-year follow-up valvular disease was revealed in 17 out of 214 RA patients (7.9%). Only 3 patients developed the disease in childhood prior to RA diagnosis. In 8 patients the diagnosis of valvular disease was established in the presence of RA, in 6 RA patients the disease was determined during the follow-up period. Mitral stenosis, aortal stenosis, combined mitral valve incompetence, combined aortal defect, mitral defect and tricuspid incompetence, combined mitral defect and pulmonary artery valvular incompetence were detected in 2, 2, 3, 1, 1, and 1 patients, respectively. Valvular disease occurs more frequently in progredient seropositive RA uncontrollable by on-going therapy. The authors emphasize the value of a prospective clinical echocardiographic examination of RA patients in early diagnosis of valvular disease in them. Frequent valvular lesions in RA patients dictate the need of persistent antirheumatic therapy to inhibit the activity and prevent progression of the disease.

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Analysis of the remission incidence and duration has been made in 71 patients with severe progressive rheumatoid arthritis (RA) during the 10-20-year follow-up period, with special attention paid to the role of the disease-modifying drugs (DMARDs). Remission occurred only in those patients who received permanent long-term systematic treatment with DMARDs. Such a therapeutic approach resulted in remission lasting from 5 to 11 years for 32% of the patients. Otherwise the patients who received episodic non-regular DMARDs therapy or symptomatic treatment with nonsteroidal anti-inflammatory drugs or steroids had no remission at all. A detailed analysis of the cases of remission is presented. The authors are of the opinion that after the disappearance of the clinical signs of RA the maintenance basic therapy may be continued.

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Analysis was made of the results of basic therapy carried out for 10-15 years in 71 patients suffering from rheumatoid arthritis (RA) bearing in mind the systematic nature of the treatment. The study included patients with the progressive disease variety and the onset of observation instituted within the first 5 years of RA. It is shown that only basic therapy carried out for many years and practically continuously during the observation period made it possible to control the disease. As a result of such treatment policy, 50% of the patients manifested for a long time (6-10 years) a pronounced decrease or complete suppression of RA activity followed by remission, which was accompanied by retardation and the ceasing of the progression of x-ray alterations and functional insufficiency of the joints. Nonsystematic basic treatment did not exert any material effect on RA. The results of such therapy in patients with the RA standing 10-20 years did not differ from those without the use of the basic drugs.

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The authors relate the results of prolonged treatment (up to 3.5 years) with colchicin of 22 patients suffering from rheumatoid arthritis (RA) complicated by morphologically verified secondary amyloidosis of the kidneys and/or of the gingival, rectal and hepatic mucosae. Colchicin prescribed as the only slowly acting agent turned out effective in 5 out of 11 patients and in all the 11 patients given the drug in combination with basic therapy by cytostatics or, rarely, by gold drugs and D-penicillamine. The treatment efficacy could be observed both in respect to the manifestations of rheumatoid disease proper and in respect to the manifestations of amyloidosis. The drug did not produce any side effects and could be administered for a long time. In the overwhelming majority of cases, the withdrawal of colchicin, even in basic therapy continuation caused the enhancement of the manifestations of RA and amyloid nephropathy.

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Analysis is made of the results of the treatment with parenteral (crysanol and myochrysine) and oral (ridaura) gold drugs as well as with small doses of D-penicillamine (DP) of patients suffering from rheumatoid arthritis with the signs of nephropathy. The latter ones were identified, respectively, in 18 out of 80 patients who began receiving treatment, in 17 out of 72, and in 16 out of 61 patients. The clinical, laboratory, instrumental and morphological manifestations of nephropathy are described and analysis of their dynamics under the treatment impact is provided. It is noted that these types of basic therapy produce a beneficial effect on the manifestations of rheumatoid nephropathy. That referred to a greater measure to the gold drugs than to the small doses of DP. The degree of counteracting the symptoms of renal pathology agreed well with a good clinical effect in respect to the articular syndrome and inflammatory responses of blood. Among patients receiving crysanol, iatrogenic nephropathy was recorded in 8.75% of cases, among those on ridaura, in 2.8%, and those on DP, in 8.2% of cases. The authors provide evidence for the use of gold drugs and DP in patients suffering from rheumatoid nephropathy.

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During a prospective observation lasting 6 years 68 patients with rheumatic arthritis (RA) were repeatedly examined (up to 8 times) roentgenologically with parallel puncture biopsy of the synovial fluid of the knee joint made with an atraumatic needle, and numerical evaluation of markedness of 25 morphological signs of synovitis. A comparative analysis of the markedness of morphological signs of synovitis in relation to the degree and dynamics of destructive changes in the knee joint was made on the basis of the findings of 254 puncture biopsies and the same amount of roentgenograms. There is a close relationship between the activity of synovitis and the progress of destructive arthritis except for the morphological signs characterizing the reaction of hypersensitivity of an immediate type that may serve the purpose of prognostication of further articular destruction and of the choice of an early adequate therapy.

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Morphological signs of rheumatoid synovitis have been analysed on the basis of 130 puncture biopsies taken from 46 patients prior to the beginning and during parenteral therapy with auric preparations (crysanolom and myocrysin) and peroral administration of an auric preparation rhidaura and small doses of D-penicillamine. The most marked morphological effect was reached in 1.5 years. With a favourable clinical effect all the preparations exhibited capacity for suppressing the following basic signs of rheumatoid synovitis: proliferative changes in the layer of synoviocytes, reaction of blast cells.

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The method of echocardiography was used to study the effect of ridaura on the functional state of the heart in patients with rheumatoid arthritis (RA) depending on the duration of therapy and its efficacy. A total of 28 patients with RA were examined in the dynamics of therapy. The favourable effect of ridaura on the size of the left ventricle of the heart and its contractile function with the general positive effect of therapy was revealed. A decrease in the size of the left ventricle began 6 months after treatment with ridaura and continued up to the end of the first year, the contractile function considerably rose after two years of treatment. In 1/3 of the patients side effects developed; they manifested themselves in deterioration of the indices of hemodynamics. The unfavourable effect of ridaurotherapy on the myocardium had a latent course and was reversible.

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Renal pathology was revealed in 284 out of 498 patients with rheumatoid arthritis (RA) subjected to the 15 years' prospective controlled follow-up and given individualized pharmacotherapy. Biopsy specimens of the kidney were examined in 90 cases. Of these, in 14 patients, they were examined repeatedly. On morphology the following alterations were detected in renal tissue: minimum morphological alterations (18 cases), glomerulonephritis (32 cases), amyloidosis (53 cases), interstitial nephritis (4 cases), and arteriosclerotic nephrosclerosis (1 case). In patients with nephropathy, no pathology nas revealed on morphology (5 cases). Chronic pyelonephritis was diagnosed in 137, nephroptosis in 47, nephrolithiasis in 17, papillary necrosis in 3, and drug nephropathy in 33 patients. Many patients had concomitant renal pathology. Repeated morphological examinations of renal tissue point to dynamic morphological alterations occurring during treatment and disease. Chlorbutin was found to exert a beneficial effect not only on the manifestations of arthritis but also on renal tissue. It could be seen in patients with a primary morphological diagnosis of mesangioproliferative nephritis and minimum morphological alterations in renal tissue. In some cases the clinical and morphological data did not agree, which provides evidence in favour of making renal biopsy in RA patients with a purpose of early diagnosis and specification of renal pathology, choice of the treatment policy.

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The paper is concerned with the data obtained during 17-year prospective follow-up of over 500 patients with rheumatoid arthritis (RA) who received individualized treatment mainly with basic drugs. Cases of repair of bone erosions in small joints of the hands and feet are described as are cases of complete or partial repair of osteolysis in 8 patients with significant RA treated for a long time with parenteral or oral gold drugs, or D-penicillamine in different daily doses.

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A total of 30 patients were treated by chrisanolum and myocrisin. The course of treatment lasted more than 2 years. The authors observed clear positive effect of parenteral preparations of gold on the contractile and pumping function of the heart in RA patients; clinical and laboratory manifestations of the disease were decreased.

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Results of a light optics morphological study of kidney biopsy material in 20 patients with rheumatoid glomerulonephritis supplemented by the data of immunofluorescent and electron microscopic diagnosis have been presented. All-round morphological investigation of biopsy material is the only proof for the presence of a renal lesion in 1/4 of the patients.

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In the period of 5 years the authors observed 213 patients with RA. Of this number 80 patients got Au parenteral preparations and 61--D-penicillamin in the average daily dose of 450 mg. The efficacy of the drugs was assessed by its effect of the indices of the activity (quantitative assessment of clinical manifestations of vascular syndrome) which had been determined by the time of treatment and on the 3, 6, 12, and 18th month of subsequent therapy.

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Ridaura was given to 72 patients with true rheumatoid arthritis (RA) in the period of 6 mos to 2 yrs. Patients with I-II degree of activity and II-III x-ray stage of RA prevailed. Extraarticular RA manifestations were detected in 79% of the patients. The efficacy of Ridaura was assessed by its effect on the indices of activity (clinical manifestations of the articular syndrome, ESR, morphological signs of rheumatoid synovitis) and progression (the rates of erosive arthritis development in the hand and foot joints, the time course of the level of the serum rheumatoid factor and RA systemic manifestations). The drug efficacy was assessed with relation to the preceding variant of a RA course by the onset of treatment and after 3, 6, 12 and 18 mos. The results obtained indicated a high clinical efficacy of the drug and the presence of its basal activity which manifested itself in a good clinical effect by a decrease in the rates of x-ray progression, a serum RF level, the expression of morphological signs of synovitis and extraarticular RA manifestations, in particular myocarditis, diffuse interstitial pulmonary fibrosis, fever, and Aschoff's nodules. The therapeutic effect of the drug was on an increase in the period over 1 year. The highest efficacy of the drug was noted in RA with persistent activity of I-II degree or with activation up to II degree. Side-effects were revealed in 19% of the patients. Good tolerance of the drug was observed in 63% of the patients with a previous history of intolerance to parenteral gold drugs.

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Of 467 patients followed-up for 15 yrs, rheumatoid arthritis was complicated by amyloidosis in 47 (10%). The relationship of amyloidosis development with a high or constantly moderate activity and expression of rheumatoid arthritis and its severity was brought to light. The results of biopsies of the mucosa, kidneys and liver, autopsy and clinical findings were analyzed and correlated. An increase in the frequency of amyloidosis development was noted in patients treated with glucocorticoids whereas in patients receiving cytostatics there was not such an increase.

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