Paradigms of megapolis nephrology in a changing world: status, problems and prospects of development of the nephrological service of St. Petersburg

   The course of the COVID-19 pandemic has led to a critical increase in the burden on virtually all major branches of the health care system in our country and abroad.   The aim of this article is to analyse the activities of the different parts of the city nephrol­ogy service in Saint-Petersburg and to consider promising ways to improve it.   The nephrology service for the adult population in St. Petersburg includes: outpatient service; inpatient service - 183 beds in 24-hour inpatient departments of the city; dialysis service - 10 dialysis units in municipal medical organizations, 5 in federal institutions, and 8 centers/departments operating in the framework of private-public partnership. The number of patients on dialysis programme decreased by 10.5 % to 1,839 in 2021. These changes are likely due to an increase in mortality among these patients in 2020 and 2021 which is a consequence not only of COVID-19 but also of the adverse impact of the pandemic on the health system. The proportion of patients treated as outpatients in private dialysis centres increased during the three-year period. The incidence of arteriovenous fistula formation in primary vascular access decreased from 33.2 % to 14.2 % in 2020 compared with 2019. At the same time, the use of temporary central venous catheters as primary vascular access for renal replacement therapy has increased significantly from 43.0 % to 61.9 %. The development of the nephrology service is largely determined by its funding. To compensate the costs of medical in­ stitutions in the city for conducting renal replacement therapy it is necessary to increase the tariffs of compulsory health insurance (CHI) by at least 50 %. In the medical organizations of Saint-Petersburg municipal and federal subordination the share of "artificial kidney" devices that have used up their resource is 32.2 %, and in a number of medical institutions it exceeds 50 %.