Delaying the development of chronic renal failure should be carried out in the early stage of chronic renal failure
(1) Diet therapy: Appropriate diet therapy is an important measure to treat chronic renal failure, because diet control can alleviate uremic symptoms and delay the destruction of nephron. ① Restrict protein's diet: Reducing the protein content in the diet can reduce the level of blood urea nitrogen (BUN), relieve uremia symptoms, and also help to reduce blood phosphorus and acidosis. Because the intake of protein is often accompanied by the intake of phosphorus and other inorganic acid ions. Giving 0.6g/kg protein every day can still meet the basic physiological needs of the body, and there is no protein malnutrition. Protein intake should be adjusted according to GFR. If GFR is 10 ~ 20ml/min, it should be 0.6g/kg per day. More than 20ml/min, can add 5 g; Less than 5ml/min can only use about 20g per day. Generally speaking, when the GFR has dropped below 50ml/min, it is necessary to carry out appropriate protein limit. But more than 60% of protein must be rich in essential amino acids such as eggs, fish, lean meat and milk (that is, high-quality protein), and try to eat less substances rich in plant protein, such as peanuts, soybeans and their products, because they contain more non-essential amino acids. ② High calorie intake: Eating enough carbohydrates and fats to supply enough calories for human body can reduce the decomposition of protein for providing calories. Therefore, a high-calorie diet can make full use of nitrogen in a low-protein diet and reduce the consumption of protein in the body. The daily heat requirement is about 125.6J/kg(30kcal/kg). Thin or obese people should add or subtract as appropriate. In order to get enough calories, you can eat more vegetable oil and sugar. For example, if you feel hungry, you can eat sweet potato taro, potato apple, horseshoe powder, yam powder and lotus root powder. Food should be rich in B vitamins, vitamin C and folic acid. Tablets can also be taken orally as supplements. ③ Others: A. Sodium intake: Except those with edema, hypertension and oliguria, it is generally inappropriate to strictly limit salt. Because in GFR,
(2) Application of essential amino acids: If GFR is less than or equal to 5ml/min, the daily intake of protein should be reduced to 20g, which can further reduce the health of nitrogen-containing metabolites in blood. However, due to the low intake of protein, protein's malnutrition will appear after more than 3 weeks, so it is necessary to add essential amino acids (EAA) or the mixture of essential amino acids and their α ketoacids, so as to keep uremic patients in a good nutritional state for a long time. Oral or intravenous injection of essential amino acids, 9 ~ 23g per day for adults. Anyone who uses this method should not eat amino acids rich in nonessential amino acids, but eat a small amount of high-quality protein [0.3g/(kg d)]. So as to promote the organism to synthesize nonessential amino acids with urea, and then synthesize human protein with essential amino acids, thereby achieving the purpose of reducing urea nitrogen. α ketoacids combine with ammonia in vivo to form the corresponding EAA. EAA is healthy in the process of protein synthesis, and part of urea can be used, so it can reduce the level of blood urea nitrogen and improve the symptoms of uremia. α ketoacid itself does not contain nitrogen, which will not cause the increase of metabolic waste in the body, but the indication of expensive EAA is only for patients with renal failure. Generally, the dosage is 0. 1 ~ 0.2g/kg per day, taken orally for three times.
(3) Control of systemic and/or intraglomerular hypertension: Systemic hypertension will promote glomerular sclerosis, so it must be controlled. ACE inhibitors or angiotensin Ⅱ receptor antagonists will also promote glomerulosclerosis, so although there is no systemic hypertension, it is appropriate to use the above drugs to delay the decline of renal function. If enalapril can be used, patients without systemic hypertension only need to take 5 ~ 10 mg every day. However, serum creatinine >: 350μmol/L may cause a sharp deterioration of renal function, so it should be used with caution.
(4) Others: The treatment of hyperlipidemia is the same as that of general hyperlipidemia patients, but the use of lipid-regulating drugs is still inconclusive. Hyperuricemia usually does not require treatment, but if gout occurs, allopurinol is taken orally at 0. 1g, once a day. (5) Colon dialysis: oral aldosterone, carbon tablets, Shenshuaining, Niaoduqing granules, Zhuoke powder rhubarb water, etc. To promote the excretion of nitrogen-containing toxins. The dosage is adjusted according to the individual differences of patients, and defecation twice a day is soft. Studies have shown that rhubarb can also slow down the occurrence of uremia. Rhubarb 10g, oyster 30g, dandelion 20g, decocted in water to 300ml for health, maintained a high enema level, 1 ~ 2 times /d for health, and discharged 3 ~ 4 times /d to promote fecal nitrogen excretion.
Treatment of complications
(1) imbalance of water and electrolyte: ① imbalance of sodium and water: patients without edema do not need to ban salt, but low salt is enough. People with edema should limit their intake of salt and water. If the edema is serious, diuretic treatment should be carried out. A. Diuretic therapy after sodium volume expansion: take sodium bicarbonate 3g/d first. If the patient has water and sodium retention, it is not necessary to take sodium bicarbonate first. Then the dose of furosemide (furosemide) is100 mg/d. Make the daily urine volume reach about 2000ml. Otherwise furosemide will double every day. However, the total amount of furosemide per day shall not exceed 1000mg. If furosemide (furosemide) exceeds 200mg each time, glucose should be added intravenously. B Vasoactive drugs: dopamine 20mg, phentolamine 10mg, 5% glucose 250ml, intravenous drip, 1ml/min, 1 time /d, 7 times in total, which can improve renal blood flow and promote urea nitrogen excretion. Those who have been dialyzed should strengthen ultrafiltration. If edema is accompanied by diluted hyponatremia, the intake of water should be strictly limited, and 500ml of water should be added on the basis of the urine volume of the previous day every day. If the balance of sodium and water is out of balance, causing serious situation, dialysis treatment should be carried out urgently when conventional treatment methods are ineffective. In some cases, although GFR is lower than 5ml/min, water and salt can still be discharged normally, which is more common in patients with chronic obstructive urinary tract disease and spinal cord injury accompanied by persistent bladder dysfunction (stones, infection, obstruction). Strict restriction of salt and water intake can lead to insufficient capacity. ② Hyperkalemia and hypokalemia: When hyperkalemia occurs, we should first judge whether hyperkalemia is caused by some aggravating factors, such as acidosis, drugs (such as spironolactone, ACE inhibitors of potassium-containing drugs, etc. ) and/or excessive potassium intake, such as a moderate increase in blood potassium. First of all, we should treat the cause of hyperkalemia and limit the intake of potassium in the diet. Patients with oliguria should limit their potassium intake, and long-acting thiazides or 1 loop diuretics can effectively prevent hyperkalemia. If hyperkalemia >: 6.5mmol/L, hyperkalemia in ECG or even myasthenia, it must be treated urgently. Start with 20 ml 10% calcium gluconate, and then slowly inject it intravenously. Then intravenous injection of 5% sodium bicarbonate 100ml for 5 minutes was completed; Then 50% glucose 50 ~ 100 ml and insulin (common insulin) 6 ~ 12U were injected intravenously. Dialysis should be performed immediately after the above treatment. The blood potassium of uremia patients is generally at a normal low level, but hypokalemia is easy to occur after using diuretics. At this time, potassium chloride or potassium citrate should be taken orally. Intravenous potassium supplementation is only needed in an emergency. ③ Metabolic acidosis: If acidosis is not serious, you can take sodium bicarbonate 1 ~ 2g 3 times /d orally. When the binding force of carbon dioxide is lower than 13.5mmol/L, especially when accompanied by coma or deep breathing, intravenous alkali should be supplemented. Generally, the binding force of carbon dioxide should be increased to 17. 1mmol/L first. 0.5ml/kg of 5% sodium bicarbonate is needed for every increase of carbon dioxide binding capacity1mmol/L. If hypocalcemia and tetany caused by acidosis are corrected, 10% calcium gluconate can be diluted and slowly injected intravenously. ④ calcium and phosphorus imbalance: hyperphosphatemia should be prevented in the early stage of chronic renal failure, and intestinal phosphorus-binding drugs should be actively used, such as oral calcium carbonate 2g at meals, three times a day, which can not only reduce blood phosphorus but also supplement calcium and correct acidosis. Aluminum hydroxide gel can also be used as phosphorus binder, but long-term use will cause aluminum poisoning, dementia, anemia, bone diseases and so on. When blood phosphorus is not high and blood calcium is too low, calcium gluconate 1g can be taken orally three times a day. Serum phosphorus and calcium levels should be monitored regularly. Keeping serum phosphorus and calcium at normal levels can prevent secondary hyperparathyroidism and some renal osteodystrophy. If blood phosphorus is normal, blood calcium is low, and secondary hyperparathyroidism is obvious (high blood FTH, high alkaline phosphatase activity and bone destruction), calcitriol should be given. If the product of phosphorus and calcium is greater than or equal to 70, metastatic calcification will not only cause calcification of organs, subcutaneous joints and blood vessels, but also be one of the incentives for the deterioration of renal function.
(2) Cardiovascular and pulmonary complications: ① Hypertension in patients with chronic renal failure is mostly volume-dependent. After removing sodium retention, blood pressure can return to normal or become easy to treat. Patients should reduce their intake of water and salt. If the diuretic effect is not ideal, dialysis dehydration can be used. Due to the retention of sodium and water, antihypertensive drugs can not play their due role in reducing hypertension (pseudodrug resistance). The use of antihypertensive drugs is the same as that of general hypertensive patients. Care should be taken to prevent hyperkalemia when using ACE inhibitors. A few patients have malignant hypertension, and the treatment method is the same as that of general malignant hypertension, but special attention should be paid to removing sodium and water retention at the same time. ② Uremic pericarditis should be actively dialyzed, 1 time /d, and dialysis 1 week is expected to improve. If there are signs of pericardial tamponade, emergency pericardiocentesis or pericardiotomy and drainage should be performed. ③ Heart failure: Its treatment is the same as general heart failure, but the curative effect is often poor. In particular, it should be emphasized that high-dose furosemide should be used to remove sodium and water retention, and dialysis ultrafiltration should be carried out if necessary. Digitalis drugs can be used, and digitoxin should also be used, but the curative effect is often not good. Sodium nitroprusside, a vasodilator, can be used, but the time should not exceed 1 week to avoid cyanide poisoning. ④ Uremic pneumonia can be treated by dialysis, and the curative effect can be achieved quickly.
(3) Hematological complications: Maintenance chronic dialysis can improve anemia of chronic renal failure. If hemoglobin is below 60 g/L, a small amount of blood transfusion should be given to those who are not qualified to use erythropoietin. Blood transfusion has the risk of hepatitis infection, which can inhibit the adverse reactions such as erythropoiesis in bone marrow. Iron deficiency should be supplemented, and hemodialysis patients often have iron deficiency. The saturation of transferrin (TSAT) should be maintained at TSAT)≥0.20, and serum ferritin should be ≥ 100mg/d, otherwise even if enough EPO is used, anemia cannot be corrected. There are three ways to supplement iron, oral, intravenous and intramuscular. The oral dose is at least 200mg of elemental iron per day, but the gastrointestinal side effects are great. At present, intravenous iron supplementation is widely recommended in western countries, which will not cause gastrointestinal reactions and directly enter the blood, so it can be better utilized, such as TSAT.
(4) Renal Osteodystrophy: Correcting the imbalance of calcium and phosphorus in the early stage of chronic renal failure can prevent most patients from secondary hyperparathyroidism and renal osteodystrophy. The indication of calcitriol [125(OH)2O3] is renal osteodystrophy, which is more common in long-term dialysis patients. This medicine can increase the absorption of calcium in the small intestine and regulate the softening of bones. It has good curative effect on osteomalacia, and also has certain curative effect on myasthenia gravis and fibrous osteitis related to renal osteodystrophy. The drug can be increased from 0.25μg per day to 0.5 ~ 1 μ g within 2 ~ 4 weeks as needed. During the treatment, blood phosphorus and blood calcium should be closely monitored to prevent the product of calcium and phosphorus >: 70 and avoid ectopic calcification. Subtotal parathyroidectomy is effective for metastatic calcification and fibrous osteitis. If the blood calcium rises and the condition does not improve, the parathyroid gland should be explored, and if there is an adenoma, it should be removed.
(5) Infection: Uremic patients are more susceptible to infection than ordinary people, and the selection and application principles of antibiotics are the same as general infection. If antibiotics are excreted through the kidney, the dose can be adjusted according to the decrease of GFR after giving the dose of 1 load. Some antibiotics have strong nephrotoxicity, such as aminoglycoside antibiotics, which will be enhanced in chronic renal failure. In the case of similar curative effect, the drug with the least nephrotoxicity should be selected.
(6) Neuropsychiatric and muscular symptoms: Adequate dialysis can improve neuropsychiatric and muscular symptoms. After successful renal transplantation, peripheral neuropathy can be significantly improved. Calcitriol and supplementary nutrition can improve the symptoms of myopathy in some patients. The use of erythropoietin (EPO) may also be effective for myopathy.
(7) Others:
① With the decline of GFR, patients with diabetic renal failure must adjust the insulin dose accordingly, and generally it should be gradually reduced.
② Skin pruritus: topical emulsified oil, oral antihistamine, controlling phosphorus intake and intensive dialysis are effective for some patients. Subtotal thyroidectomy is sometimes effective for intractable skin itching. 4. Dialysis therapy Dialysis therapy can replace the excretion function of the kidney, but it cannot replace the endocrine and metabolic functions. Hemodialysis and peritoneal dialysis have similar curative effects, but each has its own advantages and disadvantages, which 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 treatment cannot make the patient asymptomatic, dialysis treatment should be considered. Some people think that starting dialysis when GFR is slightly lower than 10ml/min can make patients get the greatest benefit. When GFR is at this level, BUN is generally above 35.7mmol/L( 100m/dl), and serum creatinine is 884μmol/L( 10mg/dL). BUN of the elderly with insufficient intake in protein should not exceed 30. When GFR is lower than 10ml/min, the whole body is still in good condition, especially the patient has too much urine and can fully excrete sodium. Individual cases can still be maintained when GFR is less than 5ml/min. In some cases, although GFR is greater than 10ml/min, dialysis is necessary, which is more common in patients with severe sodium retention and/or refractory heart failure. In addition to GFRBUN and creatinine levels, uremia can also cause pericardial inflammatory encephalopathy, severe gastrointestinal dysfunction, systemic failure, or life-threatening electrolyte disorder and acid-base balance disorder. When it exceeds 1, dialysis is needed immediately. It is best to start dialysis before these projects appear. We advocate early dialysis. Health should start dialysis as soon as possible when GFR 10ml is good for protecting the function of other organs. With the improvement of dialysis technology and medical level, old age is no longer a contraindication for dialysis. According to the registration of European Association for Dialysis and Transplantation 1983, the number of elderly patients over 65 who received dialysis (HD) has reached 8.7%, with an average age of 72.6 years. In the United States, 1987 elderly patients over 75 years old began to receive dialysis treatment, reaching 13.5%. The 2-year survival rate of hemodialysis patients over 65 years old is 665438 0%, while that of continuous ambulatory peritoneal dialysis (CAPD) patients is over 56%. It is reported that the 75-year-old patient survived through hemodialysis for more than 10 years.
(1) Hemodialysis: A few weeks before hemodialysis, the location of arteriovenous fistula should be done well in advance. Generally, in long-term intermittent hemodialysis, it is easy to puncture the forearm with a needle to make the blood flow channel. Generally, hemodialysis is performed three times a week for 4 ~ 6h hours each time. The duration of each dialysis depends on the performance and clinical situation of dialysis membrane. Within 6 weeks after starting hemodialysis, uremia symptoms gradually improved, but blood creatinine, urea nitrogen and other health indicators did not drop to normal levels. Although anemia has improved, it still exists. Renal osteodystrophy may still occur after dialysis. Due to the popularity of hemodialysis, more elderly patients with renal insufficiency at the end of the year can receive hemodialysis treatment, and most patients can get better curative effect. The incidence of cardiovascular diseases in elderly hemodialysis patients is very high, which determines whether the elderly patients can survive. Elderly patients have obvious or potential heart disease, and the mortality rate increases obviously during hemodialysis. Uremia accelerates the development of cardiovascular degeneration. Uremia is often accompanied by risk factors leading to atherosclerosis, such as hypertension, impaired glucose tolerance and hyperlipidemia, especially hypertriglyceridemia. The patient also has extensive arterial calcification, which may be related to the increase of blood phosphorus and secondary hyperparathyroidism. These risk factors must be identified and dealt with as soon as possible. Hypertension is almost common in elderly uremia patients, and it is usually controlled by antihypertensive drugs and treated with careful dialysis. Hyperlipidemia requires diet control and lipid-lowering drugs. Oral colloidal drugs, such as aluminum hydroxide, are given a low-phosphorus diet to antagonize phosphorus in food. Elderly patients should pay attention to prevent complications during dialysis, such as short circuit of hardened blood vessels. Congestive heart failure is induced by arteriovenous short circuit caused by the formation of large fistula during dialysis. The dosage of heparin must be carefully adjusted to prevent the bad consequences of massive hemorrhage to the elderly.
(2) Peritoneal dialysis: Continuous ambulatory peritoneal dialysis (CAPD) is simple, easy to master, safe and effective, and can be operated at home, so the number of users has increased year by year in recent years. A medical silica gel dialysis tube is permanently inserted into the abdominal cavity, through which dialysate is pumped into the abdominal cavity, and dialysate 1 time is exchanged every 2L and 6h, and it takes about half an hour for each time. You can do it during the break without affecting your work. It is better for CAPD to remove molecular substances and phosphorus through continuous dialysis, and uremic toxins are continuously removed, unlike hemodialysis. Therefore, patients also feel more comfortable. The curative effect on uremia is the same as hemodialysis. The device and operation of CAPD have been greatly improved in recent years, and complications such as peritonitis have greatly reduced health. Many CAPD patients have survived for more than 10 years, and the curative effect is quite satisfactory. The medical cost of CAPD is lower than that of hemodialysis. CAPD is especially suitable for the elderly with unstable cardiovascular status, patients with diabetic nephropathy or those with difficulty in making arteriovenous fistula. 5. If the patient is suitable for surgery (according to indications) and has a suitable donor, kidney transplantation is feasible. In developed countries, elderly patients with chronic renal failure under the age of 75 can still receive kidney transplantation.
repair
(1) Patients with chronic renal failure should eat less soy products and the menu should be vegetarian. Diet should be light but not salty. For patients with infection, spicy fish, shrimp, old hens and other heat-generating hair products should be banned.
(2) Patients with chronic renal failure are seriously ill and have a long course of disease, which often leads to pessimism and disappointment. At this time, they should contact patients more, encourage patients to establish confidence in overcoming diseases, eliminate concerns and maintain a good mental state.
(3) The room should be ventilated, cold-proof and sunny. Pay attention to skin care and health, take a bath often, or use warm water to rub the bath, the water temperature is 40℃. Rinse your mouth before and after meals, brush your teeth before going to bed after waking up, and keep the prognosis of oral hygiene: this disease is common in clinic, with poor treatment effect and high mortality.