Treatment of underlying diseases and factors that worsen renal failure primary chronic renal disease itself is difficult to reverse, but still should try to find and correct certain reversible factors that aggravate chronic renal failure, timely and effective treatment, so that the patient's renal function can be improved. Such as correcting water, electrolyte and acid-base balance disorders, especially sodium deficiency; timely and effective control of infections; relief of urinary tract obstruction; treatment of heart failure; stopping the use of nephrotoxic drugs, etc. According to our clinical experience, the treatment of chronic renal failure of the primary disease is an important part of the treatment, especially lupus nephritis, even if it has entered the uremic stage, there is still a reversal of the possibility. Therefore, it is of great significance to pay attention to finding and correcting the reversible factors of uremic patients, and its efficacy is far more significant than symptomatic and alternative treatments. For critically ill patients, dialysis can be used to improve the patient's general condition, in order to create conditions to win time to correct reversible factors.
Delaying the development of chronic renal failure should be carried out in the early stage of chronic renal failure
(1)Dietary treatment: appropriate dietary treatment program is an important measure in the treatment of chronic renal failure, because dietary control can alleviate the symptoms of uremia and slow down the destruction of renal units ①Protein-restricted diet: reducing the amount of protein in the diet in order not to produce a negative nitrogen balance as a principle can make the blood urea nitrogen (BUN) levels decrease, and the symptoms of uremia are reduced. The level of urea nitrogen (BUN) can be reduced, the symptoms of uremia reduced, but also conducive to reducing blood phosphorus and reduce acidosis. Because the intake of protein is often accompanied by the intake of phosphorus and other inorganic acid ions. A daily protein intake of 0.6g/kg can satisfy the basic physiological needs of the body without protein malnutrition. Protein intake, it is appropriate to make appropriate adjustments according to the GFR GFR for 10 ~ 20ml/min, with 0.6g/kg per day; greater than 20ml/min, can add 5g; less than 5ml/min can only be used every day with about 20g. It is generally believed that the GFR has been reduced to less than 50ml/min, then it is necessary to carry out the appropriate protein restriction. But more than 60% of the protein must be rich in essential amino acids protein (i.e., high biological value of high-quality protein), such as eggs, fish, lean meat and milk, etc., as far as possible, eat less vegetable protein-rich substances, such as peanuts, soybeans and their products, etc., because of its non-essential amino acid content. ② high-calorie intake: the intake of carbohydrates and fat in sufficient quantities to supply the body with sufficient calories, which can reduce the protein to provide heat and decomposition of the high-calorie diet can make the nitrogen of the low-protein diet to be fully utilized to reduce the consumption of protein in the body. Calories daily about 125.6J/kg (30kcal/kg) lean or obese people should be appropriate to be added or subtracted. In order to be able to intake enough calories, can eat more vegetable oil and sugar, such as feeling hungry, can eat sweet potato taro, potato apple, horseshoe powder, Chinese yam powder lotus root powder and other health. Food should be rich in B vitamins, vitamin C and folic acid. Tablets can also be given as oral supplements. Other: A. Sodium intake: In addition to edema, hypertension and oliguria to limit salt, generally should not be strictly limited. This is because patients can usually excrete excess healthy sodium before GFR<10ml/min, but cannot reduce sodium excretion accordingly when sodium is deficient.B. Potassium intake: as long as the urine volume is more than 1L per day, there is generally no need to restrict potassium in the diet.C. Give a low phosphorus diet, not more than 600mg per day.D. Drinking water: those who have oliguria, edema, and cardiac failure should be strictly controlled on the intake of water but for urine volume >1000ml without edema, it is inappropriate to restrict water intake Using the above dietary treatment program, most patients with uremia symptoms can be improved. For patients who have begun dialysis, the dietary regimen should be changed to that of dialysis.
(2) the application of essential amino acids: if the GFR ≤ 5ml/min to reduce the daily protein intake to about 20g, which can further reduce the health of nitrogen-containing metabolites in the blood, but due to the intake of protein is too small, such as more than 3 weeks, protein malnutrition occurs, must be added to the use of essential amino acids (EAA) or essential amino acids and their alpha keto acid mixture, can make long-term uremic patients. The addition of essential amino acids (EAA) or a mixture of essential amino acids and their alpha keto acids is necessary to maintain a better nutritional status in uremic patients over the long term. Oral or intravenous essential amino acids, adults 9 to 23 g per day, avoid eating amino acids rich in non-essential amino acids, and eat a low amount of high-quality protein [0.3 g / (kg - d)]. To promote the body to use urea to synthesize non-essential amino acids healthy and then with essential amino acids to synthesize human proteins, so as to achieve the purpose of reducing urea nitrogen. α keto acid in the body and ammonia combined into the corresponding EAA, EAA in the synthesis of protein in the process of health, you can use part of the urea, so you can reduce the level of urea nitrogen in the blood, to improve the symptoms of uremia. α keto acid itself does not contain nitrogen, will not cause the body of metabolic wastes Increase, but the price is expensive EAA indications only for patients with renal failure general dosage of 0.1 to 0.2g/kg per day, divided into three oral
(3) control of systemic and/or intraglomerular high pressure: systemic hypertension will contribute to glomerulosclerosis, so it must be controlled, the first choice of ACE inhibitors or angiotensin Ⅱ receptor antagonists intraglomerular high pressure will also contribute to glomerulosclerosis Therefore, although there is no systemic hypertension, it is also advisable to use the above drugs to delay renal decompensation. If enalapril is available, in patients without systemic hypertension, it can be taken only 5-10mg per day. however, in patients with blood creatinine >350μmol/L, it may cause rapid deterioration of renal function, so it should be used with caution.
(4) Other: the treatment of hyperlipidemia is the same as that of general hyperlipidemia, but the use of lipid-regulating drugs is still inconclusive. Hyperuricemia usually does not need treatment, but if gout occurs, it is given allopurinol 0.1g, 1 time a day orally (5) colonic dialysis: packaged aldoxyl starch, carbon tablets, renal failure, urethane particles, ketozoosan rhubarb water, etc. orally, to promote the nitrogen-containing toxins out of health. And with the patient's individual differences in dosage adjustment, make sure that the soft stool 2 times a day for the degree, research shows that rhubarb can also slow down the occurrence of uremia. Rhubarb 10g, oyster 30g, dandelion 20g, water decoction to 300ml health, high retention enema, 1 ~ 2 times / d health, diarrhea amount of 3 ~ 4 times / d appropriate to promote fecal nitrogen discharge.
Treatment of complications
(1) water, electrolyte imbalance: ① sodium, water imbalance: patients without edema, no salt ban, low salt is enough. Those with edema should limit salt and water intake. If edema is heavy, diuretic therapy should be given. a. Sodium dilatation followed by diuretic therapy: i.e., sodium bicarbonate 3g/d should be given first, if the patient already has sodium retention, it is not necessary to give sodium bicarbonate first. Then give furosemide (tachycardia) dosage started for 100mg/d static injection. Make the daily urine volume up to about 2000ml. Otherwise, the amount of tachycardia is doubled every day. However, the total amount of tachyphylaxis should not exceed 1000mg per day, such as furosemide (tachyphylaxis) more than 200mg each time, should be added to glucose in the IV.B. Vasoactive drug application: dopamine 20mg, phentolamine 10mg, added to 5% dextrose 250ml in the IV, 1ml/min, 1 time / d, **** 7 times, can improve renal blood flow, promote the excretion of urea nitrogen. Those who have been dialyzed should strengthen ultrafiltration. If edema is accompanied by dilutional hyponatremia, water intake should be strictly limited, and it is advisable to add another 500 ml of water per day for the previous day's urine volume.If the imbalance of sodium water balance results in a serious situation, which is ineffective for conventional treatment methods, dialysis treatment should be carried out urgently. In some cases, despite a GFR of less than 5ml/min, water and salt can still be excreted appropriately. This is mostly seen in chronic obstructive uropathy, and spinal cord injury with persistent bladder insufficiency (stones, infection, obstruction) Strictly restricting salt and water intake can lead to volume insufficiency. ② high potassium, low potassium: hyperkalemia should first determine whether the hyperkalemia due to certain aggravating factors such as acidosis, drugs (such as spironolactone, potassium-containing drugs ACE inhibitors, etc.) and/or excessive potassium intake, such as blood potassium is only moderately elevated, the first treatment of the cause of hyperkalemia should be limited from the dietary intake of potassium. In oliguric patients, potassium intake must be restricted, and long-acting thiazides or a combination of a labeled diuretic can be effective in preventing hyperkalemia. If hyperkalemia>6.5mmol/L is present, with electrocardiographic manifestations of hyperkalemia or even muscle weakness, it must be treated urgently. Firstly, use 10% calcium gluconate 20ml, dilute it and inject it slowly intravenously; then use 5% sodium bicarbonate 100ml to push it intravenously, and finish injecting it in 5min; then use 50% glucose 50~100ml plus insulin (ordinary insulin) 6~12U to inject intravenously. After the above treatment, dialysis should be done immediately. The blood potassium of uremic patients is generally in the normal low value, but after the use of diuretics, hypokalemia is very easy to occur, and then potassium chloride or potassium beryllate should be taken orally. Intravenous potassium supplementation should be given only in emergencies. ③Metabolic acidosis: if acidosis is not serious, oral sodium bicarbonate can be taken 1~2g 3 times/d. Carbon dioxide binding capacity is lower than 13.5mmol/L, especially when accompanied by coma or deep respiration, intravenous alkali supplementation should be given, usually to raise the carbon dioxide binding capacity to 17.1mmol/L. For every increase of carbon dioxide binding capacity by 1mmol/L, 5% sodium bicarbonate 0.5ml/kg is needed. If hypocalcemia is caused by correction of acidosis and tetany occurs, 10% calcium gluconate diluted in 10 ml can be given slowly intravenously. Calcium-phosphorus balance disorder: should be in the early stage of chronic renal failure to prevent and control hyperphosphatemia actively use intestinal phosphorus binding drugs, such as oral calcium carbonate 2g at mealtime, 3 times / d not only can reduce blood phosphorus and can supply calcium, but also can correct acidosis. Aluminum hydroxide gel can also be used as a phosphorus binding agent, but long-term use can occur aluminum poisoning, causing dementia, anemia, bone disease. In the blood phosphorus is not high when the blood calcium is too low can be oral calcium gluconate 1g, 3 times / d. It is advisable to monitor the serum phosphorus, calcium levels. Keeping serum phosphorus and calcium at normal levels can prevent secondary hyperparathyroidism and certain renal osteodystrophies. If blood phosphorus is normal and calcium is low, and secondary hyperparathyroidism is obvious (high blood FTH, high alkaline phosphatase activity, and bone destruction), osteotriol should be given. If the phosphorus-calcium product is elevated ≥70, metastatic calcification is prone to occur not only cause visceral, subcutaneous, joint and vascular calcification, but also one of the triggers of deterioration of renal function
(2) cardiovascular and pulmonary complications: ① most of the hypertension in patients with chronic renal failure is volume-dependent, and after removing the sodium and water retention, the blood pressure can be restored to normal or become easily treatable. Patients are advised to reduce water and salt intake if diuresis is unsatisfactory and dialysis can be used for dehydration. Because in the case of sodium and water retention, antihypertensive drugs can not play the proper role to make high blood pressure drop (pseudo-resistance). The use of antihypertensive drugs is the same as in general hypertensive patients. When using ACE inhibitors, caution should be taken to prevent causing hyperkalemia. Malignant hypertension occurs in a small number of patients and is treated in the same way as general malignant hypertension, but special attention should be paid to removing sodium and water retention at the same time. ② Uremic pericarditis should be aggressively dialyzed 1x/d, and improvement can be expected after about 1 week of dialysis. If there are signs of pericardial tamponade, emergency pericardiocentesis or pericardiotomy and drainage. (iii) Heart failure: its treatment is the same as that of general heart failure, but the efficacy is often poor. Special attention should be paid to emphasize the removal of sodium, water retention using larger doses of furosemide dialysis ultrafiltration when necessary. Digitalis drugs can be used preferably digitalis glycosides, but the efficacy is often poor. Can use vasodilator sodium nitroprusside, but pay attention to the time should not exceed 1 week, in order to avoid cyanide poisoning. ④ Uremic pneumonia can be used dialysis therapy, can quickly get the effect.
(3) hematologic complications: maintenance chronic dialysis, can improve the anemia of chronic renal failure. In those who are not in a position to use EPO, if the hemoglobin is less than 60g/L, then small amounts of multiple blood transfusions should be given. Blood transfusion carries the risk of infections such as hepatitis and can inhibit bone marrow production of erythrocytes, among other adverse effects Iron supplementation should be given to those with iron deficiency, which is more common in hemodialyzed patients. Should maintain transferrin saturation (TSAT) ≥ 0.20, serum ferritin ≥ 100 mg / d otherwise even the use of adequate amounts of EPO can not make the anemia correction up to standard. There are 3 ways of iron supplementation i.e. oral, intravenous, intramuscular oral dose is at least 200mg of elemental iron per day, but gastrointestinal side effects are large at present, intravenous iron supplementation is generally recommended in the western countries, which not only does not cause gastrointestinal reactions, but also goes directly into the blood, which can be better utilized, e.g., TSAT<0.20 or serum ferritin<100mg/L. Adults should be given first 1 month once a year of 25mg of Iron dextrose or iron gluconate IV drip as a test, if no adverse reaction IV drip 100mg, **** 10 times, 1 course of treatment end of discontinuation of drugs 2 weeks after the review of HCT, Hb, TSAT serum ferritin. If still low health, then intravenous iron supplementation 50-100mg, once a week, *** 10 weeks. If TSAT<0.50 and serum ferritin<800mg/L are up to standard, intravenous iron supplementation can be discontinued for 3 months. If respectively ≤50 and ≤800<800mg/L can be used 1/2 ~ 1/3 of the dose to continue intravenous iron supplementation such as HCT, TSAT, serum ferritin have reached the standard can also be used weekly intravenous iron supplementation 25 ~ 100mg to maintain the intravenous iron supplementation may cause side effects, allergic reactions (shortness of breath, wheezing hypotension) incidence rate of about 0.65%. Mostly occur within minutes of sedation with iron gluconate. With epinephrine adrenocorticotropic hormone can take effect immediately. Delayed reaction for arthralgia muscle pain in a dose-dependent manner, the dose of ≤ 100mg rarely occurs healthy erythropoietin (recombinant human erythropoietin healthy rHuEPO, referred to as EPO) for the treatment of anemia in renal failure its efficacy is remarkable. It can be used in patients who have done dialysis and those who have not yet done dialysis. After the anemia improves, cardiovascular function, mental status and energy will improve, which can improve the quality of life of patients In order to make erythropoietin (EPO) play a full role, should be supplemented with enough hematopoietic raw materials, such as iron and folic acid. At the beginning, erythropoietin (EPO) dosage is 50U/kg 3 times a week, except for hemodialysis patients who are more convenient to inject intravenously, other patients should be injected subcutaneously. Hemoglobin (Hb) and hematocrit (HCT) should be checked once a month. If the monthly increase of Hb is less than 10g/L or HCT is less than 0.03, then the dosage of EPO should be increased by 25 U/kg each time until the Hb rises to 120g/L or the HCT rises to a healthy 0.35. At this time, the dose of erythropoietin (EPO) should be 50 U/kg three times a week, except for hemodialysis patients where intravenous injection is more convenient. At this point, the erythropoietin (EPO) dose can be gradually reduced, and adjusted once a month to reduce the amount of erythropoietin (EPO) by approximately 25 U/kg each time while maintaining the above levels, which are generally sufficient to maintain a good quality of life. However, if maintenance erythropoietin (EPO) is not used, the patient will become anemic again soon after stopping the medication. The main side effects of erythropoietin (EPO) are high blood pressure, headaches and occasional seizures. The cause may be increased blood viscosity and increased vascular resistance due to increased red blood cells. Strictly control the speed and level of Hb or HCT rise can reduce the side effects of erythropoietin (EPO), we observed that the domestic erythropoietin erythropoietin (Ninghongxin) efficacy is better, and the price is appropriate, the beginning of the 3,000U / times, three times a week, Hb rose to 110g / L can be reduced to maintain
(4) renal osteodystrophy: in the early stage of chronic renal failure, pay attention to correct the calcium-phosphorus balance imbalance, you can prevent most of the renal bone dystrophy. Balance imbalance in the early stage of chronic renal failure, you can prevent most patients from developing secondary hyperparathyroidism and renal osteodystrophy. Osteotriol [125(OH)2O3] is indicated for use in renal osteodystrophy, most often in patients on long-term dialysis. This drug increases calcium absorption from the small intestine and regulates bone softening. It is effective in osteochondrosis, and is also effective in myopathic muscle weakness and fibrous osteitis associated with renal osteodystrophy. 0.25 μg of this drug orally per day can be increased to 0.5-1 μg in 2-4 weeks as needed, and blood phosphorus and calcium should be closely monitored during treatment to prevent calcium-phosphorus multiplication >70 to avoid ectopic calcification. Subtotal parathyroidectomy is effective for metastatic calcification and fibrous osteitis. If blood calcium is elevated without improvement parathyroid glands should be explored if adenomas are present they should be removed.
(5) infection: uremia patients are more prone to infections than normal people, the choice of antibiotics and the application of the same principles as the general infection. If the antibiotic is excreted by the kidney, it can be given 1 loading dose and then adjust its dose according to the decline in GFR. Some antibiotics have strong nephrotoxicity, such as aminoglycoside antibiotics, and nephrotoxicity is enhanced in chronic renal failure. In the case of similar efficacy, the drug with the least nephrotoxicity should be chosen.
(6) Neuropsychiatric and muscular system symptoms: adequate dialysis can improve neuropsychiatric and muscular system symptoms after successful renal transplantation, peripheral neuropathy can be significantly improved. Osteotriol and intensive supplementation can improve the symptoms of myopathy in some patients. The use of erythropoietin (EPO) may also be effective in myopathy.
(7) Other:
①In patients with diabetic renal failure, as the GFR continues to decline, insulin dosage must be adjusted accordingly, and generally should be gradually reduced.
②Itchy skin: topical emulsified oils, oral antihistamines, control of phosphorus intake and intensive dialysis are effective in some patients. Subtotal thyroidectomy is sometimes effective for persistent pruritus.4. Dialysis therapy Dialysis therapy can replace the excretory function of the kidneys but not the endocrine and metabolic functions. Hemodialysis and peritoneal dialysis have similar efficacy but each has its own advantages and disadvantages, and can complement each other in clinical application. There is no consensus on the timing of dialysis. When chronic renal failure reaches the end stage and conservative therapy cannot make the patient asymptomatic, dialysis should be considered. Some people believe that GFR is slightly less than 10ml/min that is to start dialysis can make the patient to get the most benefit, GFR in this level BUN is generally in 35.7mmol / L (100m / dl) or more, serum creatinine in 884μmol / L (10mg / dL), in the protein intake insufficient in the elderly BUN may not exceed 35.7mmol / L. When GFR is less than 10ml / min, the systemic status of the patient can not exceed 35.7mmol / L. When the GFR is less than 10ml / min, the systemic status of the patient is less than 10 ml / min, the systemic status of the patient is less than 10 ml / min. When the GFR is less than 10 ml/min, the systemic status is still very good, especially when the patient has a good urine output and is able to excrete sodium adequately. In some cases, the GFR is less than 5 ml/min and can still be maintained. In some cases, dialysis is necessary despite a GFR greater than 10 ml/min, mostly in patients with severe sodium retention and/or persistent heart failure. In addition to GFRBUN and creatinine levels uremia-induced pericarditis encephalopathy, severe gastrointestinal dysfunction, systemic failure, or life-threatening electrolyte disturbances and acid-base balance imbalances require dialysis therapy when more than 1 of these is present, preferably starting dialysis before these manifestations are seen. We advocate that dialysis should be started at an early stage, with a healthy GFR of 10 ml/min, which is conducive to the protection of other organ functions. With the improvement of dialysis technology and medical standards, advanced age is no longer a contraindication to dialysis. According to the registry of the European Dialysis and Transplantation Association in 1983, the number of elderly patients over 65 years old who received dialysis (HD)) therapy has reached 8.7%, with an average age of 72.6 years. In the United States, the number of elderly patients over the age of 75 who began dialysis therapy reached 13.5% in 1987. 2-year survival rates for hemodialysis patients over the age of 65 reached 61%, and 2-year survival rates for continuous ambulatory peritoneal dialysis (CAPD) reached more than 56%; survival by hemodialysis has been reported to reach more than 10 years in elderly patients at the age of 75.
(1) hemodialysis: a few weeks before hemodialysis, should be made in advance arteriovenous endovascular fistula position is generally in the forearm in the long-term intermittent hemodialysis easy to use a needle puncture made blood flow channel. Generally, hemodialysis is performed 3 times a week, each time 4-6 h. The length of each dialysis depends on the performance of the dialysis membrane and the clinical condition. Within 6 weeks of starting hemodialysis, the symptoms of uremia gradually improve, however, the blood creatinine and urea nitrogen health will not drop to the normal level. Anemia improves but remains. Renal osteodystrophy may still develop after dialysis. As a result of the spread of hemodialysis, more elderly patients with end-stage renal insufficiency can be treated with hemodialysis and most of them will have a better outcome. The prevalence of cardiovascular disease in elderly patients on hemodialysis is high and determines survival. Elderly patients with significant or underlying cardiac disease have a significantly increased mortality rate on hemodialysis. The development of cardiovascular degeneration is accelerated by uremia, which is often associated with risk factors for atherosclerosis, such as hypertension, poor glucose tolerance, and hyperlipidemia, especially hypertriglyceridemia. Patients also have extensive arterial calcification, which may be associated with elevated serum phosphates and secondary hyperparathyroidism Health. These risk factors must be identified and treated as early as possible. Hypertension is almost universal in elderly uremic patients and is commonly controlled with antihypertensive medications and cautiously treated with dialysis. Hyperlipidemia requires dietary control and use of lipid-lowering drugs. Hyperphosphatemia is given a low phosphorus diet with oral colloidal drugs such as aluminum hydroxide to antagonize phosphorus in food. Elderly patients on dialysis should be careful to prevent complications such as short circuiting of hardened blood vessels. Arteriovenous short circuits made surgically during dialysis induce congestive heart failure due to the formation of large fistulas. Heparin dosage must be carefully adjusted to prevent hemorrhage, which has adverse consequences in the elderly.
(2) peritoneal dialysis: continuous ambulatory peritoneal dialysis therapy (CAPD) equipment is simple, easy to operate, safe and effective, can be operated at home, so the last 10 years, the use of the people are increasing year by year. A medical silicone dialysis tube is permanently inserted into the peritoneal cavity, and the dialysis solution is fed into the peritoneal cavity through it. 2L of dialysis solution is exchanged once every 6h, and the solution is exchanged 4 times a day, each time taking about half an hour, and it can be done during the rest time without interfering with the work. CAPD is a continuous dialysis that removes the intermediate molecular substances and phosphorus better, and the uremic toxins are removed continuously without fluctuating as in the case of hemodialysis. As a result, patients also feel more comfortable. The efficacy of CAPD is the same as that of hemodialysis, and the device and operation of CAPD have been greatly improved in recent years, and complications such as peritonitis have been greatly reduced. Many patients with CAPD have survived for more than 10 years with satisfactory results. the medical cost of CAPD is lower than that of hemodialysis. CAPD is especially suitable for the elderly with unstable cardiovascular conditions, diabetic nephropathy or those who have difficulties in making arteriovenous endovascular fistulae. 5. renal transplantation Renal transplantation can be done if the patient is suitable for the operation (meets the indications) and there is a suitable donor. In developed countries, the elderly CRF patients under 75 years old can still do kidney transplantation.
Rehabilitation
(1) Patients with chronic renal failure should eat less soy products, and the menu is mainly vegetarian. Diet should be light and not salty for patients with co-infections, should be prohibited to take spicy fish and shrimp old hen and other heat-assisted hair health.
(2) patients with chronic renal failure, the condition is heavy, the course of the disease is long, resulting in patients often pessimistic mood, this time should be more contact with the patient, to encourage the patient to set up confidence in overcoming the disease, to eliminate the concerns to maintain a good state of mind.
(3) The room should be ventilated, warm and cold should be appropriate, and there should be sufficient sunlight. Should pay attention to skin care health, often bathing, or with warm water bath, the water temperature to 40 ℃ Celsius is appropriate. Mouth rinsing should be done before and after meals, and teeth should be brushed before going to bed and after waking up in order to maintain oral hygiene Prognosis: This condition is common in clinical practice, and the seriousness of the condition is poorly treated, with a very high case fatality rate