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Chronic kidney disease

     Chronic kidney disease (CKD) Definition: Chronic renal structural and functional impairment (history of renal impairment> 3 months) due to various causes, including normal and abnormal renal pathological changes, abnormality of blood or urine composition, and imaging Check the abnormal, or unexplained decline in GFR (<60ml / min · 1.73m2) more than 3 months, is CKD.

  Caused by chronic kidney disease, including a variety of primary, secondary glomerulonephritis, renal tubular injury and renal vascular lesions. According to GFR can be divided into five stages of chronic kidney disease, early detection and early intervention can significantly reduce the complications of CKD patients, significantly improve the survival rate, for the treatment of CKD, including primary disease treatment, various risk factors Treatment and delay the progress of chronic renal failure, when the progression of CKD patients to 5, should be timely renal replacement therapy.

  Staging

  In recent years, the American Kidney Disease Foundation K / DOQI Expert Group has proposed new recommendations for the staging of CKD, as shown in the following table, which treats patients with GFR ≥90 ml / min · 1.73m2 and with nephropathy as 1 Period CKD, its purpose is to strengthen the early understanding of CKD and early prevention and treatment.

  Table staging of chronic kidney disease

  Staging

  description

  GFR [ml / (min. 1.73 m2

  Description

  1

  Renal injury index (+), GFR normal

  > 90

  GFR without exception, focus on diagnosis and treatment of primary disease

  2

  Renal injury index (+) GFR decreased slightly

  60 to 89

  Slow down the progress of CKD, reduce the risk of cardiovascular disease

  3

  GFR moderate drop

  30 to 59

  Slows CKD progression, and evaluates treatment complications

  4

  GFR severe drop

  15-29

  Comprehensive treatment, treatment of complications

  5

  Kidney failure

  <15 or dialysis

  Dialysis preparation and dialysis treatment

  Etiology

  The etiology of CKD mainly includes primary glomerulonephritis, hypertensive renal arteriosclerosis, diabetic nephropathy, secondary glomerulonephritis, tubulointerstitial lesions (chronic pyelonephritis, chronic uric acid nephropathy, obstructive nephropathy, Drug-induced nephropathy, etc.), ischemic nephropathy, hereditary nephropathy (polycystic kidney disease, hereditary nephritis). In developed countries, diabetic nephropathy, hypertension, renal arteriosclerosis has become a major cause of chronic kidney disease; in our country, these two diseases in various causes still ranked after primary glomerulonephritis, but in recent years there are significant Increasing trend. According to statistics, the US adults (a total of about 200 million) the prevalence of CKD has reached 11.3%. According to some reports in China, CKD prevalence rate of about 10%. CKD risk factors are: age (such as old age), CKD family history (including genetic and non-hereditary nephropathy), diabetes, hypertension, obesity - metabolic syndrome, high-protein diet, hyperlipidemia, hyperuricemia (Such as hepatitis B or C virus) infection, urinary stones, urinary tract obstruction, urinary tract or systemic cancer, the application of nephrotoxic drug history, cardiovascular disease (such as hepatitis B virus infection), urinary tract infection, urinary tract infection, systemic infection, , Anemia, smoking, low birth weight and so on. Other risk factors are environmental pollution, low economic level, low level of health insurance, education and low.

  Clinical manifestations

  In the different stages of CKD, its clinical manifestations are also different. Before the CKD3 period, the patient can have no symptoms, or only fatigue, backache, nocturia increased mild discomfort; a small number of patients may have anorexia, metabolic acidosis and mild anemia. CKD3 period later, the symptoms become more obvious, after entering the renal failure period is further aggravated, and sometimes there may be high blood pressure, heart failure, severe hyperkalemia, acid-base balance disorders, gastrointestinal symptoms, anemia, mineral bone metabolism , Hyperparathyroidism and central nervous system disorders, and even life-threatening.

  1. Gastrointestinal symptoms

  The most common is gastrointestinal symptoms, mainly manifested in loss of appetite, nausea, vomiting, oral urine smell.

  2. Gastric and duodenal inflammation, ulcers, bleeding

  Gastric and duodenal inflammation, ulcers, bleeding is more common, the incidence was higher than normal. CKD patients with blood system abnormalities mainly manifested as renal anemia and bleeding tendency. Most patients are generally mild to moderate anemia, the main reason for the lack of erythropoietin, it is called renal anemia. Excessive fluid or acidosis can occur when shortness of breath, shortness of breath and other respiratory symptoms, severe acidosis can cause deep breathing. Excessive body fluids, heart failure can cause pulmonary edema or pleural effusion. Some patients with severe may be associated with uremia, pulmonary edema, uremia pleurisy, uremia pulmonary calcification.

  3. Cardiovascular disease

  Cardiovascular disease is one of the major complications of CKD and the most common cause of death. With the continuous deterioration of renal function, heart failure significantly increased the prevalence to uremia up to 65% to 70%. Heart failure is the most common cause of death in uremic patients. Atherosclerosis and vascular calcification in hemodialysis patients are more severe than in pre-dialysis patients, and atherosclerosis tends to develop more rapidly. Uremic cardiomyopathy and metabolic waste retention and anemia and other factors, pericardial effusion in CKD patients is also quite common.

  4. neuromuscular system symptoms

  Neuromuscular system symptoms in CKD early may have insomnia, inattention, memory loss and so on. With the progression of the disease often response indifference, convulsions, hallucinations, drowsiness, coma, mental disorders. Peripheral neuropathy is also common. Hypocalcemia, hyperphosphatemia, active vitamin D deficiency can induce secondary hyperparathyroidism (referred to as hyperparathyroidism); these factors lead to renal osteodystrophy (ie renal bone disease), including Fibrocystic osteitis (high turnover bone disease), osteomalacia (low turnover bone disease), bone formation, osteoporosis and osteoporosis.

  5. Endocrine dysfunction

  CKD patients often endocrine dysfunction, renal endocrine dysfunction itself, including: 1,25 (OH) 2 vitamin D3, erythropoietin deficiency and renal renin-angiotensin II levels; can also cause hypothalamus - Pituitary endocrine disorders: such as prolactin, melanoma hormone (MSH), luteinizing hormone (FSH), follicle-stimulating hormone (LH), adrenocorticotropic hormone (ACTH) levels increased; the majority of patients have secondary Hyperparathyroidism, insulin receptor dysfunction, glucagon increased. About 1/4 of patients with mild thyroid hormone levels decreased.

  Some patients may be associated with skin symptoms, such as pigmentation, calcium calm, itching, sweating difficulties, ulcers. Some patients may have hypogonadism, manifested as gonadal dysplasia or atrophy, low libido, amenorrhea, infertility, etc., may be related to serum sex hormone levels, uremic toxins, certain nutrients (such as zinc) and other factors.

  treatment

  In order to clarify the different stages of CKD control objectives, the concept of tertiary prevention is necessary. The so-called primary prevention, also known as primary prevention, refers to the existing kidney disease or may cause kidney damage disorders (such as diabetes, hypertension, etc.) for timely and effective treatment, prevention of chronic renal failure (CRF). Secondary prevention, is the light to moderate CRF patients in time for treatment, delay, stop or reverse the progress of chronic renal failure, prevention and treatment of uremia. The third level of prevention, refers to the early treatment of uremic patients to take measures to prevent the occurrence of some serious complications of uremia, improve patient survival and quality of life.

  The end result of the progression of chronic renal insufficiency is end-stage renal failure (ESRF), and patients will have to rely on renal replacement therapy to sustain life. Despite significant advances in dialysis, ESRF mortality is still high and the quality of life is low. Thus, treatment of patients with CKD includes treatment of chronic progression of renal insufficiency and treatment of various comorbidities.

  1. Delay the occurrence and progress of chronic renal insufficiency

  (1) primary disease treatment of primary disease caused by CKD treatment.

  (2) to delay the progress of chronic renal insufficiency delayed chronic renal insufficiency, including the following measures:

  1) to control blood pressure to actively control blood pressure can reduce proteinuria, can reduce glomerular hyperfiltration, slow the progress of chronic renal failure lesions. The principle of choice of antihypertensive drugs according to the different stages of CKD, when CCr> 30ml / min, the preferred angiotensin converting enzyme inhibitor (ACEI) or angiotensin Ⅱ receptor antagonist (ARB), if necessary Combined with other antihypertensive drugs. When the patient's Ccr down to 30ml / min below, the application of ACEI and ARB may cause glomerular hypoperfusion pressure leaving the glomerular filtration rate is too low, so the non-dialysis patients with CKD should be used with caution.

  2) Diet Low protein diet can reduce glomerular hyperperfusion, high blood pressure and high filtration, reduce proteinuria, thus slowing down glomerular sclerosis in patients with glomerulosclerosis and interstitial fibrosis progress. When the GFR is less than 25ml / (min.l73rm ²), the amount of protein should be limited to 0.6g / (kg.d). Should ensure that sufficient calorie intake is greater than 35kcal / (kg.d), in order to maximize the use of dietary protein. In addition to the necessary amino acids or keto acid amino acid mixture. In addition, patients with high blood pressure and edema should limit salt intake. Patients with dyslipidemia should be dietary adjustments, if necessary, should be lipid-lowering drug therapy.

  3) to correct the rapid increase in chronic renal failure factors CRF is a slow progression of the disease, but patients with a variety of risk factors for a high susceptibility in the course of the deterioration of renal function may be. Common risk factors are: ① hypovolemia, including hypotension, dehydration, shock, etc.; ② severe infection, sepsis; ③ tissue trauma or bleeding; ④ endogenous or exogenous toxins kidney damage; ⑤ urethral obstruction; Failure to control severe hypertension and malignant hypertension. Carefully identify the cause of accelerated renal function and the reasons for the progress of targeted therapy, help to improve renal function.

  2.CRF prevention and treatment of complications

  (1) to maintain water and electrolyte balance, correct metabolic acidosis should be based on urine output, blood pressure, edema, etc. to adjust the intake and output, whether to limit the intake of sodium depends on the presence of hypertension and edema. Hyperkalemia appears to correct the predisposing factors, while giving 5% sodium bicarbonate intravenous drip, intravenous glucose plus insulin, 10% calcium gluconate intravenous injection, oral potassium resin treatment, the above measures ineffective or severe high (> 6.5mmol / L) need to be hemodialysis treatment. Metabolic acidosis is common in patients with CRF, it is through the protein metabolism and 1,25 (OH) 2D3 generation in the role of malnutrition and renal bone disease. Mild acidosis only oral sodium bicarbonate, the heavier (carbon dioxide binding <15rnmol / L) will need intravenous sodium bicarbonate treatment.

  (2) prevention and treatment of cardiovascular disease strict control of blood pressure, blood lipids, blood sugar, to avoid excessive capacity overload, correct metabolic acidosis, correct bad habits (such as smoking, too little activity, etc.) are conducive to reduce cardiovascular complications happened.

  (3) to correct renal anemia application of recombinant human erythropoietin renal anemia can be corrected, the target value of hemoglobin up to 100 ~ 120g / L, hematocrit 31% to 32%. Correct anemia can improve the vital organs, especially the heart of the blood supply and function, improve the quality of life of patients with CRF. When using erythropoietin to pay special attention to iron supplement, because iron deficiency is a common cause of its efficacy.

  (4) prevention and treatment of renal bone disease by limiting the intake of phosphorus in the diet, phosphorus binders used to correct hyperphosphatemia. Hypocalcemia to add calcium. In patients with hyperparathyroidism, based on the control of blood phosphorus can be given to l, 25 (OH) 2D3 treatment, medication should be closely monitored during the process of calcium, phosphorus and total parathyroid hormone (iPTH) levels, iPTH (Normal reference value of 10 to 65 pg / ml, but uremic patients to maintain normal bone turnover need higher than the normal level of iPTH), while avoiding the occurrence of hypercalcemia and metastatic calcification of the target value of 150 ~ 200pg / ml .

  When CKD patients progress to ESRD, renal replacement therapy, including hemodialysis, peritoneal dialysis, and kidney transplantation, should be performed. The choice of renal replacement therapy is based on the patient's specific circumstances.

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