Факторы риска и госпитальные исходы острого почечного повреждения, развившегося после коронарного шунтирования, у больных стабильной стенокардией - Журнал Терапевтический архив № 9 Вопросы кардиологии 2018
Факторы риска и госпитальные исходы острого почечного повреждения, развившегося после коронарного шунтирования, у больных стабильной стенокардией
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Аннотация
Цель исследования – оценка частоты, факторов риска и госпитальных исходов острого почечного повреждения (ОПП), развившегося после коронарного шунтирования (КШ), у больных стабильной стенокардией (СС).
Материалы и методы. В исследование включали больных СС с показаниями к КШ. Обследовано 93 пациента в возрасте 58±7,6 года с длительностью ишемической болезни сердца (ИБС) 6±6,0 года. Ранее перенесли инфаркт миокарда (ИМ) 79,6% больных. Артериальная гипертензия имелась у 92,5% лиц. Многососудистое коронарное поражение зарегистрировано у 94,6%, стеноз ствола левой коронарной артерии >50% – у 16,1% больных. КШ в условиях искусственного кровообращения выполнено у 89,2%, на работающем сердце – у 10,8% пациентов. Исходно, в первые, вторые сутки после КШ определяли уровень креатинина в крови методом Jaffe. Наличие и тяжесть ОПП после КШ оценивали по критериям KDIGO (2012). Учитывали госпитальные осложнения: случаи сердечной смерти, интраоперационного инфаркта миокарда (иИМ), инсультов, пароксизмов фибрилляции предсердий (ПФП), острой сердечной недостаточности (ОСН) по потребности в установке контрпульсатора и применению адреналина.
Результаты. Доля лиц с развившимся транзиторным ОПП I стадии после КШ составила 31,2%, II стадии – 3,2%. Развитие ОПП взаимосвязано со случаями ОСН. Увеличение продолжительности терапии адреналином более медианы 1±1,8 дня повышало относительный риск развития ОПП в 1,9 раза. Частота случаев сердечной смерти, иИМ, инсультов, ПФП не различалась среди больных с ОПП и без такового.
Заключение. Частота транзиторного ОПП после КШ составила 34,4%. Развитие ОПП ассоциировано с ОСН, возникшей во время КШ. Частота госпитальных осложнений не различалась среди больных с ОПП после КШ и без такового.
Ключевые слова: коронарное шунтирование, острое почечное повреждение, острая сердечная недостаточность.
Materials and methods. The study included patients with stable angina pectoris and indications for coronary artery bypass grafting. We examined 93 patients aged 58±7.6 years, with duration of coronary heart disease 6±6.0 years. Previous myocardial infarction had 79.6% of patients. Arterial hypertension was present in 92.5% of patients. Multi-vessel coronary disease was registered in 94.6%, stenosis of the left main coronary artery > 50% was in 16.1% of patients. Coronary artery bypass grafting in conditions of artificial circulation was performed in 89.2% of patients, coronary grafting on working heart was held in 10.8% of patients. At initial stage, on the first and second days after coronary grafting the level of creatinine was determined by the method of Jaffe. The presence, the severity of acute kidney injury after (AKI) coronary artery bypass grafting was evaluated according to the criteria KDIGO (2012). We took into account in-hospital complications: cardiac death, intraoperative myocardial infarction (iMI), stroke, atrial fibrillation (AF), acute heart failure (AHF) according to requirement in intraaortic balloon pump, and the use of adrenaline.
Results. The proportion of persons with transient AKI stage 1 after coronary artery bypass grafting was 31.2%, those of 2 stage was 3.2%. The development of AKI was associated with cases of AHF. The increase in the duration of therapy with adrenaline – more than 1±1.8 days (median) – was connected with increase of the relative risk of AKI developing in 1.9 times. The incidence of cardiac death, iMI, strokes, paroxysmal AF did not differ among patients with AKI and without it.
Conclusion. The frequency of transient AKI after coronary artery bypass grafting was 34.4%. The development of AKI is associated with AHF that occurred during coronary artery bypass grafting. The frequency of hospital complications did not differ among patients with AKI after coronary artery bypass grafting and without it.
Keywords: coronary artery bypass grafting, acute kidney injury, acute heart failure.
Материалы и методы. В исследование включали больных СС с показаниями к КШ. Обследовано 93 пациента в возрасте 58±7,6 года с длительностью ишемической болезни сердца (ИБС) 6±6,0 года. Ранее перенесли инфаркт миокарда (ИМ) 79,6% больных. Артериальная гипертензия имелась у 92,5% лиц. Многососудистое коронарное поражение зарегистрировано у 94,6%, стеноз ствола левой коронарной артерии >50% – у 16,1% больных. КШ в условиях искусственного кровообращения выполнено у 89,2%, на работающем сердце – у 10,8% пациентов. Исходно, в первые, вторые сутки после КШ определяли уровень креатинина в крови методом Jaffe. Наличие и тяжесть ОПП после КШ оценивали по критериям KDIGO (2012). Учитывали госпитальные осложнения: случаи сердечной смерти, интраоперационного инфаркта миокарда (иИМ), инсультов, пароксизмов фибрилляции предсердий (ПФП), острой сердечной недостаточности (ОСН) по потребности в установке контрпульсатора и применению адреналина.
Результаты. Доля лиц с развившимся транзиторным ОПП I стадии после КШ составила 31,2%, II стадии – 3,2%. Развитие ОПП взаимосвязано со случаями ОСН. Увеличение продолжительности терапии адреналином более медианы 1±1,8 дня повышало относительный риск развития ОПП в 1,9 раза. Частота случаев сердечной смерти, иИМ, инсультов, ПФП не различалась среди больных с ОПП и без такового.
Заключение. Частота транзиторного ОПП после КШ составила 34,4%. Развитие ОПП ассоциировано с ОСН, возникшей во время КШ. Частота госпитальных осложнений не различалась среди больных с ОПП после КШ и без такового.
Ключевые слова: коронарное шунтирование, острое почечное повреждение, острая сердечная недостаточность.
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Materials and methods. The study included patients with stable angina pectoris and indications for coronary artery bypass grafting. We examined 93 patients aged 58±7.6 years, with duration of coronary heart disease 6±6.0 years. Previous myocardial infarction had 79.6% of patients. Arterial hypertension was present in 92.5% of patients. Multi-vessel coronary disease was registered in 94.6%, stenosis of the left main coronary artery > 50% was in 16.1% of patients. Coronary artery bypass grafting in conditions of artificial circulation was performed in 89.2% of patients, coronary grafting on working heart was held in 10.8% of patients. At initial stage, on the first and second days after coronary grafting the level of creatinine was determined by the method of Jaffe. The presence, the severity of acute kidney injury after (AKI) coronary artery bypass grafting was evaluated according to the criteria KDIGO (2012). We took into account in-hospital complications: cardiac death, intraoperative myocardial infarction (iMI), stroke, atrial fibrillation (AF), acute heart failure (AHF) according to requirement in intraaortic balloon pump, and the use of adrenaline.
Results. The proportion of persons with transient AKI stage 1 after coronary artery bypass grafting was 31.2%, those of 2 stage was 3.2%. The development of AKI was associated with cases of AHF. The increase in the duration of therapy with adrenaline – more than 1±1.8 days (median) – was connected with increase of the relative risk of AKI developing in 1.9 times. The incidence of cardiac death, iMI, strokes, paroxysmal AF did not differ among patients with AKI and without it.
Conclusion. The frequency of transient AKI after coronary artery bypass grafting was 34.4%. The development of AKI is associated with AHF that occurred during coronary artery bypass grafting. The frequency of hospital complications did not differ among patients with AKI after coronary artery bypass grafting and without it.
Keywords: coronary artery bypass grafting, acute kidney injury, acute heart failure.
Список литературы
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2. Al-Ruzzeh S, George S, Yacoub V, Amrani M. The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients. Eur J Cardiothorac Surg. 2001;20:1152-6. https://doi.org/10.016/s1010-7940(01)00978-2
3. Арутюнян Л.А., Нелаев В.С., Машкин А.М. и др. Маркеры риска фатальных и нефатальных осложнений при операциях хирургической реваскуляризации миокарда. Медицинская наука и образование Урала. 2015;2:65-9 [Arutyunyan LA, Nelaew VS, Mashkin AM, et al. Markers of fatal and non-fatal risk complications in surgical myocardial revascularization operations. Medical science and Ural education. 2015;2:65-69 (In Russ.)].
4. Kellum JA, Ronco C, Mehta R, Bellomo R. Consensus development in acute renal failure: the Acute Dialysis Quality Initiative. Critical Care. 2005;11:527-32. https://doi.org/10.1097/01.ccx.0000179935.14271.22
5. Bagshaw SM, George C, Bellomo R. A comparison of the RIFLE and ARIN criteria for acute kidney injury in critically in patients. Nephrol Dial Transplant. 2008;23:1569-74. https://doi.org/10.1093/ndt/
gfn009
6. Fliser D, Laville M, Covic A, et al. A European Renal Best Practice (ERBP) position statement of the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines on Acute Kidney Injury. Part 1: definition, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012:0:1-10. https://doi.org/ 10.1093/ndt/gfs375
7. Amaoutakis GJ, Bihorac A, Martin TD, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg. 2007;134:1554-60. https://doi.org/10.1016/j.jtcvs.2007.08.039
8. Рекомендации ESC/EACTS по реваскуляризации миокарда 2014. Российский кардиологический журнал. 2015;2:5-81 [2014 ESC/EACTS Guidelines on myocardial revascularization. Russ J Cardiol. 2015;2:5-81 (In Russ.)].
9. Кремнева Л.В., Суплотов С.Н., Арутюнян Л.А. Функция почек после коронарного шунтирования у пациентов с предиабетом. Российский кардиологический журнал. 2015;2:25-9 [Kremneva LV, Suplotov SN, Arutyunyan LA. Kidney function after coronary bypass surgery in prediabetes patients. Russ J Cardiol. 2016;2:25-9 (In Russ.)]. https://doi.org/10.15829/1560-4071-2016-2-25-29
10. Кремнева Л.В., Абатурова О.В., Шалаев С.В. Частота госпитальных сердечно-сосудистых осложнений у больных с послеоперационной дисфункцией почек после хирургической реваскуляризации миокарда. Ангиология и сосудистая хирургия. 2016:4:124-8 [Kremneva LV, Abaturova OV, Shalaev SV. Frequency of in-hospital cardiovascular complications in patients with postoperative renal dysfunction after surgical myocardial revascularization. Angiology and vascular surgery. 2016;4:124-8 (In Russ.)].
11. Comments on KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:622-3. https://doi.org/10.1038/ki2013.243
12. Zeng X, McMahon GM, Brunelli S, et al. Incidence, Outcomes, and Comparisons arcoss Definitions of AKI in Hospitalized Individuals. Clin J American Society of Nephrology. 2013;9:12-20. https://doi.org/ 10.2215/cjn.02730313
13. Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pract. 2013;479730. https://doi.org/10.1155/2013/479730
14. Morgera S, Schneider M, Neumayer HH. Long-term outcomes after acute kidney injury. Critical Care Medicine. 2008;4:193-7. https://doi.org/ 10.1097/ccm.0b013e318168cae2
15. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 2012;5:442-8. https://doi.org/10.1038/ki.2011.379
16. Bagshaw SM, Hoste EA, Braam B, et al. Cardiorenal syndrome type 3: pathophysiologic and epidemiologic considerations. Contrib Nephrol. 2013;182:137-57. https://doi.org/10.1159/000349971
17. Искендеров Б.Г., Сисина О.Н. Прогностическое значение дисфункции почек в ближайшем и отдаленном периоде после коронарного шунтирования. Кардиология. 2015;11:73-8 [Iskenderov BG, Sisina ON. Predictive value of Renal Dysfunction for Early and Long-Term Outcomes of Coronary Bypass Grafting. Kardiology. 2015;11:73-8 (In Russ.)]. https://doi.org/10.18565/cardio.2015.11.
73-78
18. Berl T. Kidney-heart interactions: epidemiology, pathogenesis, and treatment. Clin J Am Soc Nephrol. 2005;1:8-18. https://doi.org/10. 2215/cjn.00730805
19. Ronco C, Haapio M, House A, et al. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527-39. https://doi.org/10.1016/j.jacc2008.07.051
20. Авдошина С.В., Ефремовцева М.А., Виллевальде С.В., Кобалава Ж.Д. Острый кардиоренальный синдром: эпидемиология, патогенез, диагностика, лечение. Клиническая фармакология и терапия. 2013;22(4):11-7 [Avdoshina SV, Yefremovtseva MA, Villevalde SV, Kobalava JD. Acute cardiorenal syndrome: epidemiology, pathogenesis, diagnosis, treatment. Clinical pharmacology and therapy. 2013;22(4):11-7 (In Russ.)].
21. Wu VC, Wu CH, Huang TM, et al. Long-Term risk of coronary events after AKI. J Am Soc Nephrol. 2014;25:595-605. https://doi.org/10. 1681/ ASN.2013060610
2. Al-Ruzzeh S, George S, Yacoub V, Amrani M. The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients. Eur J Cardiothorac Surg. 2001;20:1152-6. https://doi.org/10.016/s1010-7940(01)00978-2
3. [Arutyunyan LA, Nelaew VS, Mashkin AM, et al. Markers of fatal and non-fatal risk complications in surgical myocardial revascularization operations. Medical science and Ural education. 2015;2:65-69 (In Russ.)].
4. Kellum JA, Ronco C, Mehta R, Bellomo R. Consensus development in acute renal failure: the Acute Dialysis Quality Initiative. Critical Care. 2005;11:527-32. https://doi.org/10.1097/01.ccx.0000179935.14271.22
5. Bagshaw SM, George C, Bellomo R. A comparison of the RIFLE and ARIN criteria for acute kidney injury in critically in patients. Nephrol Dial Transplant. 2008;23:1569-74. https://doi.org/10.1093/ndt/
gfn009
6. Fliser D, Laville M, Covic A, et al. A European Renal Best Practice (ERBP) position statement of the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines on Acute Kidney Injury. Part 1: definition, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012:0:1-10. https://doi.org/ 10.1093/ndt/gfs375
7. Amaoutakis GJ, Bihorac A, Martin TD, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg. 2007;134:1554-60. https://doi.org/10.1016/j.jtcvs.2007.08.039
8. [2014 ESC/EACTS Guidelines on myocardial revascularization. Russ J Cardiol. 2015;2:5-81 (In Russ.)].
9. [Kremneva LV, Suplotov SN, Arutyunyan LA. Kidney function after coronary bypass surgery in prediabetes patients. Russ J Cardiol. 2016;2:25-9 (In Russ.)]. https://doi.org/10.15829/1560-4071-2016-2-25-29
10. [Kremneva LV, Abaturova OV, Shalaev SV. Frequency of in-hospital cardiovascular complications in patients with postoperative renal dysfunction after surgical myocardial revascularization. Angiology and vascular surgery. 2016;4:124-8 (In Russ.)].
11. Comments on KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:622-3. https://doi.org/10.1038/ki2013.243
12. Zeng X, McMahon GM, Brunelli S, et al. Incidence, Outcomes, and Comparisons arcoss Definitions of AKI in Hospitalized Individuals. Clin J American Society of Nephrology. 2013;9:12-20. https://doi.org/ 10.2215/cjn.02730313
13. Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pract. 2013;479730. https://doi.org/10.1155/2013/479730
14. Morgera S, Schneider M, Neumayer HH. Long-term outcomes after acute kidney injury. Critical Care Medicine. 2008;4:193-7. https://doi.org/ 10.1097/ccm.0b013e318168cae2
15. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 2012;5:442-8. https://doi.org/10.1038/ki.2011.379
16. Bagshaw SM, Hoste EA, Braam B, et al. Cardiorenal syndrome type 3: pathophysiologic and epidemiologic considerations. Contrib Nephrol. 2013;182:137-57. https://doi.org/10.1159/000349971
17. [Iskenderov BG, Sisina ON. Predictive value of Renal Dysfunction for Early and Long-Term Outcomes of Coronary Bypass Grafting. Kardiology. 2015;11:73-8 (In Russ.)]. https://doi.org/10.18565/cardio.2015.11.
73-78
18. Berl T. Kidney-heart interactions: epidemiology, pathogenesis, and treatment. Clin J Am Soc Nephrol. 2005;1:8-18. https://doi.org/10. 2215/cjn.00730805
19. Ronco C, Haapio M, House A, et al. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527-39. https://doi.org/10.1016/j.jacc2008.07.051
20. [Avdoshina SV, Yefremovtseva MA, Villevalde SV, Kobalava JD. Acute cardiorenal syndrome: epidemiology, pathogenesis, diagnosis, treatment. Clinical pharmacology and therapy. 2013;22(4):11-7 (In Russ.)].
21. Wu VC, Wu CH, Huang TM, et al. Long-Term risk of coronary events after AKI. J Am Soc Nephrol. 2014;25:595-605. https://doi.org/10. 1681/ ASN.2013060610
2. Al-Ruzzeh S, George S, Yacoub V, Amrani M. The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients. Eur J Cardiothorac Surg. 2001;20:1152-6. https://doi.org/10.016/s1010-7940(01)00978-2
3. Арутюнян Л.А., Нелаев В.С., Машкин А.М. и др. Маркеры риска фатальных и нефатальных осложнений при операциях хирургической реваскуляризации миокарда. Медицинская наука и образование Урала. 2015;2:65-9 [Arutyunyan LA, Nelaew VS, Mashkin AM, et al. Markers of fatal and non-fatal risk complications in surgical myocardial revascularization operations. Medical science and Ural education. 2015;2:65-69 (In Russ.)].
4. Kellum JA, Ronco C, Mehta R, Bellomo R. Consensus development in acute renal failure: the Acute Dialysis Quality Initiative. Critical Care. 2005;11:527-32. https://doi.org/10.1097/01.ccx.0000179935.14271.22
5. Bagshaw SM, George C, Bellomo R. A comparison of the RIFLE and ARIN criteria for acute kidney injury in critically in patients. Nephrol Dial Transplant. 2008;23:1569-74. https://doi.org/10.1093/ndt/
gfn009
6. Fliser D, Laville M, Covic A, et al. A European Renal Best Practice (ERBP) position statement of the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines on Acute Kidney Injury. Part 1: definition, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012:0:1-10. https://doi.org/ 10.1093/ndt/gfs375
7. Amaoutakis GJ, Bihorac A, Martin TD, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg. 2007;134:1554-60. https://doi.org/10.1016/j.jtcvs.2007.08.039
8. Рекомендации ESC/EACTS по реваскуляризации миокарда 2014. Российский кардиологический журнал. 2015;2:5-81 [2014 ESC/EACTS Guidelines on myocardial revascularization. Russ J Cardiol. 2015;2:5-81 (In Russ.)].
9. Кремнева Л.В., Суплотов С.Н., Арутюнян Л.А. Функция почек после коронарного шунтирования у пациентов с предиабетом. Российский кардиологический журнал. 2015;2:25-9 [Kremneva LV, Suplotov SN, Arutyunyan LA. Kidney function after coronary bypass surgery in prediabetes patients. Russ J Cardiol. 2016;2:25-9 (In Russ.)]. https://doi.org/10.15829/1560-4071-2016-2-25-29
10. Кремнева Л.В., Абатурова О.В., Шалаев С.В. Частота госпитальных сердечно-сосудистых осложнений у больных с послеоперационной дисфункцией почек после хирургической реваскуляризации миокарда. Ангиология и сосудистая хирургия. 2016:4:124-8 [Kremneva LV, Abaturova OV, Shalaev SV. Frequency of in-hospital cardiovascular complications in patients with postoperative renal dysfunction after surgical myocardial revascularization. Angiology and vascular surgery. 2016;4:124-8 (In Russ.)].
11. Comments on KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:622-3. https://doi.org/10.1038/ki2013.243
12. Zeng X, McMahon GM, Brunelli S, et al. Incidence, Outcomes, and Comparisons arcoss Definitions of AKI in Hospitalized Individuals. Clin J American Society of Nephrology. 2013;9:12-20. https://doi.org/ 10.2215/cjn.02730313
13. Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pract. 2013;479730. https://doi.org/10.1155/2013/479730
14. Morgera S, Schneider M, Neumayer HH. Long-term outcomes after acute kidney injury. Critical Care Medicine. 2008;4:193-7. https://doi.org/ 10.1097/ccm.0b013e318168cae2
15. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 2012;5:442-8. https://doi.org/10.1038/ki.2011.379
16. Bagshaw SM, Hoste EA, Braam B, et al. Cardiorenal syndrome type 3: pathophysiologic and epidemiologic considerations. Contrib Nephrol. 2013;182:137-57. https://doi.org/10.1159/000349971
17. Искендеров Б.Г., Сисина О.Н. Прогностическое значение дисфункции почек в ближайшем и отдаленном периоде после коронарного шунтирования. Кардиология. 2015;11:73-8 [Iskenderov BG, Sisina ON. Predictive value of Renal Dysfunction for Early and Long-Term Outcomes of Coronary Bypass Grafting. Kardiology. 2015;11:73-8 (In Russ.)]. https://doi.org/10.18565/cardio.2015.11.
73-78
18. Berl T. Kidney-heart interactions: epidemiology, pathogenesis, and treatment. Clin J Am Soc Nephrol. 2005;1:8-18. https://doi.org/10. 2215/cjn.00730805
19. Ronco C, Haapio M, House A, et al. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527-39. https://doi.org/10.1016/j.jacc2008.07.051
20. Авдошина С.В., Ефремовцева М.А., Виллевальде С.В., Кобалава Ж.Д. Острый кардиоренальный синдром: эпидемиология, патогенез, диагностика, лечение. Клиническая фармакология и терапия. 2013;22(4):11-7 [Avdoshina SV, Yefremovtseva MA, Villevalde SV, Kobalava JD. Acute cardiorenal syndrome: epidemiology, pathogenesis, diagnosis, treatment. Clinical pharmacology and therapy. 2013;22(4):11-7 (In Russ.)].
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Авторы
Л.В. КРЕМНЕВА, С.Н. СУПЛОТОВ
Кафедра клинической лабораторной диагностики ФПК и ППС ФГБОУ ВО «Тюменский государственный медицинский университет»
Минздрава России, Тюмень, Россия
Department of clinical and laboratory diagnostics, faculty of advanced physicians, Tyumen State Medical University, Tyumen, Russia
Кафедра клинической лабораторной диагностики ФПК и ППС ФГБОУ ВО «Тюменский государственный медицинский университет»
Минздрава России, Тюмень, Россия
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Department of clinical and laboratory diagnostics, faculty of advanced physicians, Tyumen State Medical University, Tyumen, Russia
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