chronic glomerulonephritis
Introduction
Introduction to chronic glomerulonephritis Chronic glomerulonephritis (chronicglomerulonephritis) is a group of primary glomerular diseases composed of many different causes and different pathological types. The clinical features are long course, slow development, mild or severe symptoms, and an abnormal period of asymptomatic urine test. Then there are different degrees of edema, proteinuria, microscopic hematuria, and may be associated with hypertension and/or azotemia. , and progressively worsened renal dysfunction. basic knowledge The proportion of illness: 0.005%, mostly from acute glomerulonephritis Susceptible people: no special people Mode of infection: non-infectious Complications: malnutrition, chronic nephritis, anemia, uremia, hypertension, cardiomyopathy, pericarditis, renal insufficiency, edema
Cause
Causes of chronic glomerulonephritis
Immune Deficiency (45%):
Immune function defects can reduce the body's ability to resist infection, resulting in repeated invasion of microorganisms; the body can not produce enough antibodies to remove pathogenic substances (antigens), so that the antigen can continue to remain in the body, and form immune complexes, deposited in Kidney tissue, which produces a chronic inflammatory process.
Infection (15%):
There are many upper respiratory tract infections or other infections before the onset. A few chronic nephritis may have evolved from nephritis after acute streptococcal infection, but most chronic nephritis is not delayed by acute nephritis.
Glomerular lesions (15%):
Other primary glomerular diseases have been directly developed.
Pathogenesis
Because chronic nephritis is not an independent disease, its pathogenesis is different, most of which are immune complex diseases, which can be deposited in the glomerulus by circulating soluble immune complexes, or by antigen and antibody in situ in the glomerulus. The complex, which activates complement to cause tissue damage, may also pass through the immune complex, but the bacterial toxin, metabolites deposited on the glomerular region, activate the complement through the "bypass system", thereby causing a series of inflammatory reactions leading to the kidney. Small ball inflammation.
In addition, non-immune-mediated renal damage may also play an important role in the occurrence and development of chronic nephritis. This non-immune mechanism includes the following factors: 1 intrarenal arteriosclerosis caused by glomerular lesions, intrarenal artery Hardening can further aggravate ischemic damage of the renal parenchyma; 2 renal hemodynamic compensatory changes cause glomerular damage, when part of the glomerulus is involved, the glomerular filtration rate of the healthy nephron is compensated, This high perfusion, high filtration state can make the glomerular sclerosis, and ultimately to renal failure; 3 hypertension causes renal arteriosclerosis, long-term hypertension causes ischemic changes, leading to renal artery stenosis, occlusion Accelerate glomerular sclerosis, hypertension can also increase glomerular capillary hydrostatic pressure, cause glomerular hyperfiltration, accelerate glomerular sclerosis; 4 glomerular mesangial overload state, normal kidney Small mesangial cells have phagocytosis and clear immune complex function, but when the load is too heavy, it can cause mesangial matrix and cell proliferation, and finally to harden.
In short, chronic glomerulonephritis, prolonged course, continuous development of lesions, gradual destruction of glomerular capillaries, mesangial matrix and fibrous tissue hyperplasia, leading to glomerular fibrosis, hyaline degeneration, tubular atrophy, interstitial Inflammatory cell infiltration and fibrosis, and eventually the renal tissue is severely damaged to form a terminal pyknotic kidney.
Prevention
Chronic glomerulonephritis prevention
Once the disease is clearly diagnosed, it should be actively treated and prevented to prevent progressive deterioration of renal function, and try to avoid and delay the patient's entry into the stage of renal replacement therapy.
1 to avoid infection, fatigue and other factors that aggravate the condition.
2 Strictly control the diet to ensure adequate nutrition.
3 actively control and treat complications.
4 Use with or without nephrotoxicity and drugs that are easy to induce kidney damage.
5 using traditional Chinese medicine treatment, according to the patient's condition, syndrome differentiation and treatment, legislation and prescription, using traditional Chinese medicine to improve and delay the progress of renal failure.
Complication
Chronic glomerulonephritis complications Complications malnutrition chronic nephritis anemia uremia hypertensive cardiomyopathy pericarditis renal insufficiency edema
1. Infection: Long-term proteinuria leads to a large loss of protein, malnutrition, immune dysfunction, and various infections, such as respiratory infections, urinary tract and skin infections. Infection, as a malignant stimulator, often induces acute exacerbation of chronic nephritis, making the disease Progressive exacerbation, although a variety of antibiotics are available at present, if the treatment is not timely or incomplete, infection is still the main cause of acute exacerbation of chronic nephritis and should be given high priority.
2. Renal anemia: renal parenchymal damage occurs in the late stage of chronic nephritis, which can be complicated by various abnormalities of the blood system, such as anemia, abnormal platelet function, abnormal lymphocyte function and coagulation mechanism disorder, among which anemia is the most common complication, anemia The main reasons are: 1 reduction of red blood cell production; 2 increased red blood cell destruction: in renal failure, uremic toxins accumulate in the body, red blood cell metabolism is disordered and easy to destroy, hemolysis occurs, leading to anemia, 3 blood loss: about 25% of patients with advanced renal failure Significant bleeding can occur, aggravating anemia.
3. Hypertension: Chronic nephritis renal dysfunction, often with serious cardiovascular complications, such as hypertension, atherosclerosis, cardiomyopathy, pericarditis and renal insufficiency, etc., mainly due to chronic nephritis renal dysfunction Period (CRF) itself is caused by metabolic abnormalities in the development process. According to statistics, the incidence of hypertension is 70%-80%. Patients requiring renal replacement therapy have almost all hypertension, and 3/4 of them use low-salt diet and dialysis. Can control high blood pressure, another 1/4 of patients with dialysis to remove excess sodium and water in the body, blood pressure is increased, in addition, CRF patients with hypertension has its inherent characteristics, showing a loss of night physiological blood pressure decline, part Can be divided into simple systolic hypertension.
Symptom
Chronic glomerular nephritis symptoms common symptoms double renal cortex thinning loss of appetite persistent urine protein plasma albumin lower blood urinary protein bacterial infection erythrocytosis increased acid absorption
The clinical manifestations of this disease are diversified. Early patients may have no obvious symptoms, or they may only show an increase in urinary protein, an increase in urinary sediment erythrocytes, and a tubular shape, sometimes accompanied by fatigue, burnout, backache, loss of appetite, and sometimes edema. Mostly eyelid edema and (or) depressed edema of the lower extremities, generally no body cavity effusion, glomerular filtration function and tubular dilute dilution function is normal or mildly impaired, some patients can be highlighted as persistent moderately above Hypertension, retinal hemorrhage, exudation, and even optic disc edema may occur. Some patients may present with a large amount of proteinuria (urinary protein > 3.5g/24h), or even nephrotic syndrome, after non-specific virus and bacterial infection. There may be sudden deterioration. In acute exacerbation of patients with chronic nephritis, a large amount of proteinuria may occur, even gross hematuria, increased tubular shape, increased edema, hypertension, and deterioration of renal function. The condition can be restored to the original level after proper treatment, but some patients This leads to disease progression and entry into the uremia phase.
Chronic nephritis may vary depending on the nature of the disease, and the course of the disease may vary significantly. From the first discovery of urinary abnormalities to the development of chronic renal failure, it may last for several years, even decades, hypertension, infection, improper diet, and application of nephrotoxic drugs. And sustained proteinuria, etc., can accelerate chronic nephritis into chronic renal failure, chronic nephritis is generally divided into three types:
1. Chronic nephritis - common type : the most common type, patients may have weakness, fatigue, waist pain, loss of appetite, sometimes no edema, generally not very serious, often accompanied by mild to moderate hypertension, facial imaginary Yellow, pale, fundus arterial thinning, arteriovenous cross compression, urine test showed moderate proteinuria (less than 3.0g / d), urine sediment has red blood cells and various casts, creatinine clearance decreased; phenol red discharge decreased , urinary enrichment function and increased serum creatinine and urea nitrogen, azotemia, may have varying degrees of anemia, increased erythrocyte sedimentation rate, slightly lower plasma albumin, slightly higher cholesterol, this type of disease progresses slowly, eventually due to kidney Death of function failure.
2. Chronic nephritis-renal type: a common type of chronic nephritis, characterized by a large amount of proteinuria (no selective proteinuria), urinary proteinuria more than 3.5g/dl per day, high edema and decreased plasma albumin, usually Less than 3g / dl, hypercholesterolemia, more than 250mg / dl, urine sediment examination, may have red blood cells and various casts, normal or moderately elevated blood pressure, normal or progressive renal function, serum creatinine and blood Increased urea nitrogen, creatinine clearance and phenol red excretion are reduced, patients may have anemia, erythrocyte sedimentation rate is significantly accelerated, this type of nephritis can be relieved after appropriate treatment.
3. Chronic nephritis-hypertensive type : In addition to the above-mentioned common chronic nephritis, it is characterized by persistent high-grade hypertension, and is not sensitive to general antihypertensive drugs, often causing severe fundus hemorrhage or flocculation. Exudation, even optic disc edema, decreased vision, accompanied by renal damage, urine test has different degrees of proteinuria and urinary sediment abnormalities, this type of renal function deteriorates quickly, poor prognosis.
The above clinical classification is not absolute, and there is a crossover and mutual transformation between the various types. Some patients have both nephrotic and hypertensive manifestations and can be mixed.
Examine
Examination of chronic glomerulonephritis
1. Urine routine examination: often have mild, moderate proteinuria, accompanied by hematuria, red blood cell cast, gross hematuria is rare, mostly for continuous hematuria under the microscope.
2. Blood examination: early changes are not obvious, positive pigmentation, positive cell anemia, erythrocyte sedimentation rate, plasma albumin decrease, blood cholesterol slightly increased, serum complement C3 is normal.
3. Renal function test: 1 endogenous creatinine clearance rate and phenol red excretion decreased slightly, urine concentration decreased, 2 serum urea nitrogen and creatinine were basically normal in the early stage, with the condition increased BUN, Scr gradually increased, when it was higher than normal At the time, it has been proved that 60% to 70% of the effective nephron has been damaged, and it is more valuable for the diagnosis of renal insufficiency, especially uremia.
4. Abdominal X-ray film: The kidney is obviously reduced and the surface is not smooth.
5. B-ultrasound: early kidneys are normal or shrinking, renal cortex is thin or renal structural disorder, B-ultrasound can help to exclude congenital renal hypoplasia, polycystic kidney disease and urinary tract obstructive disease.
6. Renal biopsy: According to its pathological type, the corresponding pathological changes can be seen.
Diagnosis
Diagnosis and diagnosis of chronic glomerulonephritis
Diagnostic criteria:
According to the clinical manifestations of chronic nephritis, the diagnosis is not difficult, the onset is slow, the condition is prolonged, the urine test is abnormal, often proteinuria, sometimes accompanied by hematuria, edema and hypertension, with varying degrees of renal dysfunction as the disease progresses, the diagnostic criteria Yes: 1 There is edema, high blood pressure and progressive damage to renal function. There are proteinuria with or without hematuria. 2 The course of disease is delayed for more than 1 year, 3 except for secondary and hereditary nephritis.
Differential diagnosis:
The most important differential diagnosis is renal changes secondary to glomerular nephropathy and systemic disease. The following is a differential diagnosis of different types of chronic nephritis.
1. Chronic nephritis nephropathy type and glomerular nephropathy: the two points are: a large number of proteinuria, high edema and hypoproteinemia, but patients with glomerular nephropathy, no microscopic hematuria, generally no hypertension and kidney Insufficient function, unless there is temporary renal dysfunction or hypertension due to severe edema, both of which should return to normal soon after diuresis, so there are even microscopic hematuria or persistent hypertension. Renal dysfunction, generally nephritis can not be diagnosed as kidney disease, such as further analysis of urinary protein, more helpful for diagnosis, glomerular nephropathy is mostly highly selective proteinuria; chronic nephritis nephropathy patients are mostly no choice Sexual proteinuria, nephropathy rarely occurs in the urine and chronic nephritis is more common. In addition, most patients with glomerular nephropathy are sensitive to hormone and immunosuppressive drugs, while patients with chronic nephritis and kidney disease have poor response to these drugs.
2. Identification of chronic nephritis common type and chronic pyelonephritis: in the advanced stage of chronic pyelonephritis, there may be a large amount of proteinuria and hypertension, which is difficult to distinguish from chronic nephritis. The latter is more common in women and often has a history of urinary tract infection. Urine sediment examination and urinary bacterial culture positive, which is helpful for the diagnosis of active infectious chronic pyelonephritis. In patients with chronic pyelonephritis, renal function damage is mainly caused by renal tubular damage, may be perchloric acid poisoning, low phosphorus Renal osteopathy, while azotemia and uremia are mild, and progress is very slow, intravenous pyelography and radionuclide kidney and kidney scan, if there is asymmetrical renal damage, it is more helpful for chronic Diagnosis of pyelonephritis.
3. Chronic nephritis, nephropathy or common and the identification of lupus erythematosus: lupus nephritis clinical manifestations and renal histological changes are similar to chronic nephritis, and lupus erythematosus women are prone to, and is a systemic disease, often accompanied by Fever, rash, arthritis, etc., blood cells are decreased, immunoglobulin is increased, lupus cells and antinuclear antibodies are present, serum complement levels are decreased, and renal histological examination reveals that immune complexes are widely deposited in various parts of the glomerulus. IgG immunofluorescence staining was strongly positive, that is, "full hall bright" performance.
4. Chronic nephritis hypertension and primary hypertension secondary: differential diagnosis of renal damage occurs in young adults, high blood pressure secondary renal damage occurs later, the history is very important, is high blood pressure, or proteinuria In the first place, the main role of differential diagnosis, in patients with hypertension secondary to kidney damage, the amount of urinary protein is often less, rare persistent hematuria and red blood cell cast, and renal damage is more serious, kidney puncture Often helpful in identification, it was found that 20% of the initial diagnosis of essential hypertension, confirmed by renal puncture as chronic nephritis.
5. Other primary glomerular diseases: 1 occult glomerulonephritis: clinically mild chronic nephritis should be differentiated from occult glomerulonephritis, the latter mainly manifested as asymptomatic hematuria and / or proteinuria , edema, hypertension and renal dysfunction, 2 acute nephritis after infection: chronic nephritis with pre-infection and acute onset needs to be differentiated from the disease, the incubation period of the two is different, the dynamic changes of serum complement C3 help Identification; In addition, the disease has different outcomes, chronic nephritis has no self-healing tendency, and it is chronically progressive and can be distinguished.
6. Others: allergic purpuric nephritis, diabetic capillary arteriolar atherosclerosis, gout kidney, multiple myeloma kidney damage, amyloidosis involving the kidney, etc., the above diseases have their own characteristics, should be excluded when the diagnosis of chronic nephritis.
7.Alport syndrome: common in adolescents, the onset is mostly before the age of 10, the patient has eyes (spherical crystals, etc.), ears (neural deafness), kidney (hematuria, mild, moderate proteinuria and progressive renal impairment) Abnormal, but this syndrome has a positive family history (mostly sexually linked dominant inheritance).
