chronic renal insufficiency
Introduction
Introduction to chronic renal insufficiency Chronic renal insufficiency, also known as chronic renal failure (CRF), refers to chronic progressive renal parenchymal damage caused by various causes, resulting in significant atrophy of the kidneys, unable to maintain its basic functions, clinically occurring with retention of metabolites Water, electrolytes, acid-base balance disorders, systemic system involvement is the main manifestation of clinical syndrome, also known as uremia. The main causes are primary glomerulonephritis, chronic pyelonephritis, hypertensive renal arteriosclerosis, diabetic nephropathy, secondary glomerulonephritis, tubulointerstitial disease, hereditary kidney disease, and long-term use of antipyretic and analgesic Agent and contact with heavy metals. Renal insufficiency in the first phase, renal insufficiency compensatory period, serum creatinine (Scr) 133 ~ 177umol / L, due to the large renal compensatory capacity, so the clinical renal function has decreased, but its excretion of metabolites and regulating water The electrolyte balance ability can still meet the normal needs, clinical symptoms do not appear, renal function tests are also in the normal range or occasionally slightly higher. basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: non-infectious Complications: hypertension, anemia, heart failure, pericarditis, cardiomyopathy, fracture
Cause
Causes of chronic renal insufficiency
Chronic glomerulonephritis (20%):
Such as IGA nephropathy, membrane proliferative glomerulonephritis; focal segmental sclerosing glomerulonephritis and mesangial proliferative glomerulonephritis. When the nephron is destroyed to a certain amount, the residual metabolic capacity of the remaining nephron is increased, and the compensatory glomerular capillary hyperperfusion, high pressure and high filtration cause glomerular epithelial cell foot processes. Fusion, glomerular endothelial cell injury, increased glomerular permeability, forming a vicious circle, leading to progressive deterioration of renal function, leading to kidney failure.
Abnormal creatinine (30%):
Such as diabetic nephropathy, gouty nephropathy and amyloidosis nephropathy; chronic renal failure caused by diabetes accounts for almost 27%, creatinine level is much higher than the normal range, and the heart has different degrees of damage.
Vascular lesions (20%):
Such as hypertension, renal vascular hypertension, renal arteriosclerosis and so on.
Genetic factors (3%):
Such as polycystic kidney disease, Alport syndrome and so on.
Infection (5%):
Such as chronic pyelonephritis, kidney tuberculosis and so on.
Systemic systemic lesions (3%):
Such as lupus nephritis, vasculitis, kidney damage, multiple myeloma.
Toxic substances (3%):
Such as analgesic nephropathy, heavy metal toxic kidney disease.
Obstructive lesions (5%):
Such as ureteral obstruction; reflux nephropathy, urinary tract stones and so on.
Prevention
Chronic renal insufficiency prevention
First, there must be a reasonable amount of protein intake. The metabolites in the human body are mainly derived from the protein components in the diet. Therefore, in order to reduce the workload of the remaining kidneys, the protein intake must be compatible with the excretion ability of the kidneys. For example, when the serum creatinine is 170 ~ 440 micromol / liter, the protein is preferably 0.6 grams per kilogram of body weight per day, a large amount of proteinuria, each additional 1 gram of urine protein, can be supplemented with 1.5 grams of protein. When the serum creatinine exceeds 440 mol/L, the protein intake should be further reduced to a total of no more than 30 g per day. However, it must be emphasized that if blindly pursuing restrictions on protein intake, it will lead to malnutrition, decreased physical fitness, and poor results.
Second, in order to maximize the use of the ingested protein, it is not allowed to be converted into energy consumption, and a low-protein diet must be supplemented with energy. At least 35 kilocalories per kilogram of body weight per day, mainly supplied by sugar, can eat fruit, sugar products, chocolate, jam, honey and so on.
Third, it is worth noting that some foods meet the previous conditions, such as egg yolk, meat pine, animal offal, dairy products, bone marrow, etc., but they are not suitable for consumption because of their high phosphorus content, because the storage of phosphorus can promote The function of the kidneys is further aggravated. In order to reduce the amount of phosphorus in food, fish, meat, potatoes, etc. should be cooked before cooking.
Fourth, the amount of salt should be determined according to the condition. If you have high blood pressure or edema, you should use a low-salt diet, 2 grams of salt per day.
Fifth, drugs excreted by the kidney may also damage the kidneys, such as gentamicin, sulfa antibiotics, penicillin, indomethacin, paracetamol, and hormones and contrast agents.
Complication
Chronic renal insufficiency complications Complications, hypertension, anemia, heart failure, pericarditis, cardiomyopathy, fracture
Often complicated by hypertension, anemia, heart failure, pericarditis, cardiomyopathy, hydroelectric disorders and acid-base imbalance, renal osteodystrophy, fractures, infections, etc.
In addition to the above systemic complications, long-term dialysis patients with chronic renal failure can also have the following complications:
Aluminum poisoning
Patients with end-stage renal disease treated with conventional dialysis are prone to aluminum toxicity.
2. Dialysis-related amyloidosis
Dialysis-related amyloidosis (DRA) is an osteoarthrosis found in long-term dialysis patients. The clinical symptoms and incidence are closely related to the length of dialysis.
3. Trace element changes
Renal failure and dialysis have a great influence on the metabolism of trace elements, and they accumulate in various parts of the body to cause toxicity.
(1) Aluminum: See aluminum poisoning.
(2) Copper: Plasma copper levels in patients with chronic renal failure who are not dialysis are often normal, but can be slightly lower.
(3) Zinc: Chronic renal failure eating low-protein diet and nephrotic syndrome, a large number of urine protein loss in patients with plasma zinc is often extremely low.
Symptom
Symptoms of chronic renal insufficiency Common symptoms proteinuria oliguria, loss of appetite, polyuria, water, sodium, sputum, azotemia, metabolic acidosis, dehydration, renal osteodycholysis, hematuria
Renal insufficiency in the first phase, renal insufficiency compensatory period, serum creatinine (Scr) 133 ~ 177umol / L, due to the large renal compensatory capacity, so the clinical renal function has decreased, but its excretion of metabolites and regulating water The electrolyte balance ability can still meet the normal needs, clinical symptoms do not appear, renal function tests are also in the normal range or occasionally slightly higher.
Renal insufficiency in the second phase, renal insufficiency decompensation period (also known as renal insufficiency azotemia period), serum creatinine (Scr) 177 ~ 443umol / L, glomerular sclerosis fibrosis increased, about 60 damage %-75%, there are certain obstacles in the kidney excretion of metabolic waste, and the serum creatinine urea nitrogen is higher or exceeds the normal value. The patient has anemia, fatigue, weight loss, difficulty in concentration, etc., but is often overlooked. If there is a situation such as loss of water, infection, or bleeding, the progress of the disease will accelerate.
Glomerular lesions:
Renal insufficiency in the third stage, renal failure, serum creatinine (Scr) 443-707umol / L, glomerular sclerosis, renal tubulointerstitial fibrosis, renal vascular fibrosis, leading to severe renal impairment, anemia, Nocturia increased, serum creatinine, blood urea nitrogen increased significantly, and often acidosis, this period without formal treatment, will develop into end-stage renal disease, treatment is more difficult.
Renal insufficiency, stage 4, uremia or renal insufficiency, serum creatinine (Scr) > 707umoll / L. Patients with renal insufficiency in uremia are more than 95% of glomerular lesions, with severe clinical symptoms such as severe nausea, vomiting, oliguria, edema, malignant hypertension, severe anemia, itchy skin, and urinary odor.
Examine
Chronic renal insufficiency examination
I. Laboratory inspection
Urine check
The urine routine protein is generally >2.0g/L, and the urine protein is reduced when the renal function damage is obvious. The morning urine specific gravity is reduced to below 1.018, or fixed at around 1.010.
Because of anemia in CRF, blood routine examination has an important role in CRF. Other tests include plasma total protein, albumin, globulin and their ratio determination; blood electrolytes (HCO3--, K, Na, Ca, Mg2, P3, etc.) levels.
Serum creatinine (Scr), urea nitrogen (BUN) increased, urine concentration-dilution function measurement showed a decrease in endogenous creatinine clearance (Ccr).
4. Liver function and two pairs of hepatitis B check.
5. Serum immunological examination
Including serum IgA, IgM, IgG, complement C3, complement C4, T lymphocyte subsets, B lymphocyte group CD4 / CD8 ratio and so on.
6. Malnutrition index detection
Serum total protein, serum albumin, serum transferrin white and low molecular weight proteins were determined. Very low levels of cholesterol are also considered indicators of malnutrition.
Second, imaging examination
Kidney B ultrasound
The thickness of the renal cortex is <1.5 cm, and the CRF is judged to be superior to the size of the kidney. Such as kidney atrophy, support end-stage diagnosis.
2. Other
Conventional electrocardiogram, X-ray, bone and gastroscopy, as well as some special examinations such as X-ray, radionuclide kidney scan, CT and magnetic resonance to determine the shape and size of the kidney and the presence or absence of urinary tract obstruction, Water, stones, cysts and tumors are helpful.
Diagnosis
Diagnosis and diagnosis of chronic renal insufficiency
The identification of CRF (chronic renal failure) and prerenal azotemia is not difficult. The renal function of patients with pre-renal azotemia can be restored after 48-72 hours of effective blood volume supplementation, while the renal function of CRF is difficult. restore.
The identification of CRF and acute renal failure is not difficult in most cases, and it is often possible to make a differential diagnosis based on the patient's medical history. When the patient's medical history is not detailed, it can be analyzed by means of imaging examination (such as B-ultrasound, CT, etc.) or renal graph examination results, such as the obvious reduction of the kidneys, or the kidney map suggesting chronic lesions, then support the diagnosis of CRF.
