The fourth stage of renal failure. Maintaining close to normal levels of calcium and phosphorus in the blood
Renal failure is a serious complication of various renal pathologies, and a very common one. The disease can be treated, but the organ cannot be restored. Chronic renal failure is not a disease, but a syndrome, that is, a set of signs indicating impaired renal function. The causes of chronic failure can be various diseases or injuries, as a result of which the organ is damaged.
Stages of kidney failure
Water, nitrogen, electrolyte and other types of metabolism in the kidney depend on the functioning of the kidney. human body. Kidney failure is evidence of failure to perform all functions, leading to disruption of all types of balance at once.
Most often, the cause is chronic diseases, in which the kidney parenchyma is slowly destroyed and replaced by connective tissue. Kidney failure becomes the last stage of such ailments - urolithiasis and the like.
The most indicative sign of pathologies is the daily volume of urine - diuresis, or minute. The latter is used when examining the kidneys using the clearance method. With normal kidney function, daily urine output is about 67–75% of the volume of fluid drunk. In this case, the minimum volume required for the organ to function is 500 ml. Therefore, the minimum volume of water that a person should consume per day is 800 ml. With standard water consumption of 1–2 liters per day, daily diuresis is 800–1500 ml.
In renal failure, urine volume changes significantly. In this case, there is both an increase in volume - up to 3000 ml, and a decrease - up to 500 ml. The appearance of daily diuresis of 50 ml is an indicator of kidney failure.
There are acute and chronic renal failure. The first is characterized by the rapid development of the syndrome, pronounced symptoms, and severe pain. However, most of the changes that occur with acute renal failure are reversible, allowing renal function to be restored within a few weeks with appropriate treatment.
The chronic form is caused by the slow irreversible replacement of the kidney parenchyma with connective tissue. In this case, it is impossible to restore the functions of the organ, and in later stages surgical intervention is required.
Acute renal failure
Acute renal failure is a sudden, severe disruption of the functionality of an organ associated with suppression of excretory function and the accumulation of nitrogen metabolism products in the blood. In this case, a disorder of water, electrolyte, acid-base, and osmotic balance is observed. Changes of this kind are considered potentially reversible.
ARF develops within a few hours, less often within 1–7 days, and becomes so if the syndrome is observed for more than a day. Acute renal failure is not independent disease, but secondary, developing against the background of other diseases or injuries.
The causes of acute renal failure are:
- low blood flow rate;
- tubular damage;
- obstruction of urine flow due to obstruction;
- destruction of the glomerulus with loss of capillaries and arteries.
The cause of acute renal failure serves as the basis for appropriate qualifications: according to this criterion, prerenal acute failure is distinguished - 70% of all cases, parenchymal - 25% and obstructive - 5%.
According to medical statistics, the causes of such phenomena are:
- surgery or trauma – 60%. The number of cases of this kind is constantly growing, as it is associated with an increase in the number of operations under artificial circulation;
- 40% are treatment related. The use of nephrotoxic drugs, necessary in some cases, leads to the development of acute renal failure. This category also includes acute poisoning with arsenic, mercury, and mushroom poison;
- 1–2% appear during pregnancy.
Another classification of the stages of the disease is used, related to the patient’s condition; 4 stages are distinguished:
- elementary;
- oligoanuric;
- polyuric;
- recovalescence.
Causes of acute renal failure
initial stage
Signs of the disease depend on the cause and nature of the underlying disease. Caused by stress factors - poisoning, blood loss, injury.
- Yes, when infectious lesion organ symptoms coincide with the symptoms of general intoxication - headache, lethargy, muscle weakness, possible fever. In case of complications intestinal infection Vomiting and diarrhea may occur.
- If acute renal failure is a consequence of poisoning, then anemia, signs of jaundice, and possible seizures are observed.
- If the cause is acute kidney disease– for example, there may be blood in the urine and severe pain in the lower back.
Changes in diuresis at the initial stage are unusual. Pallor, a slight decrease in blood pressure, and a rapid pulse may be observed, but there are no characteristic signs.
Diagnosis at the initial stage is extremely difficult. If acute renal failure occurs against the background of an infectious disease or acute poisoning, the disease is taken into account during treatment, since kidney damage due to poisoning is a completely natural phenomenon. The same can be said for those cases when the patient is prescribed nephrotoxic drugs.
A urine test at the initial stage indicates not so much acute renal failure as it does the factors that provoke the deficiency:
- the relative density for prerenal OPN is higher than 1.018, and for renal OPN is lower than 1.012;
- slight proteinuria and the presence of granular or cellular casts are possible in renal acute renal failure of nephrotoxic origin. However, in 20–30% of cases this sign is absent;
- in case of injury, tumor, infection, urolithiasis, a greater number of red blood cells is detected in the urine;
- a large number of white blood cells indicates infection or allergic inflammation urinary tract;
- if uric acid crystals are found, urate nephropathy can be suspected.
For any stages of acute renal failure a bacteriological urine test is prescribed.
A general blood test corresponds to the primary disease; a biochemical test at the initial stage can provide evidence of hyperkalemia or hypokalemia. However, mild hyperkalemia – less than 6 mmol/l, does not cause changes.
Clinical picture of the initial stage of acute renal failure 
Oligoanuric
This stage in acute renal failure is the most severe and can pose a threat to both life and health. Its symptoms are much better expressed and characteristic, which makes it possible to quickly establish a diagnosis. At this stage, nitrogen metabolism products quickly accumulate in the blood - creatinine, urea, which in a healthy body are excreted in the urine. Potassium absorption decreases, which destroys the water-salt balance. The kidney does not perform a supporting function acid-base balance, resulting in metabolic acidosis.
The main signs of the oligoanuric stage are:
- decreased diuresis: if the daily urine volume drops to 500 ml, this indicates oliguria, if it drops to 50 ml, anuria;
- intoxication with metabolic products - skin itching, nausea, vomiting, tachycardia, rapid breathing;
- a noticeable increase in blood pressure, conventional antihypertensive drugs do not work;
- confusion, loss of consciousness, possible coma;
- swelling of organs, cavities, subcutaneous tissue. Body weight increases due to fluid accumulation.
The stage lasts from several days - an average of 10-14 - to several weeks. The duration of the period and methods of treatment are determined by the severity of the lesion and the nature of the primary disease.
Symptoms of the oligoanuric stage of acute renal failure 
Diagnostics
At this stage, the primary task is to separate anuria from acute urinary retention. To do this, catheterization of the bladder is performed. If no more than 30 ml/hour is still excreted through the catheter, it means that the patient has acute renal failure. To clarify the diagnosis, an analysis of creatinine, urea and potassium in the blood is prescribed.
- With the prerenal form, there is a decrease in sodium and chlorine in the urine, the rate of fractional excretion of sodium is less than 1%. With calcium necrosis in oliguric acute renal failure, the rate increases from 3.5%, in non-oliguric acute renal failure - to 2.3%.
- For differentiation, the ratio of urea in blood and urine, or creatinine in blood and urine is specified. In the prerenal form, the ratio of urea to plasma concentration is 20:1, in the renal form it is 3:1. For creatinine, the ratio will be similar: 40 in urine and 1 in plasma with prerenal acute renal failure and 15:1 with renal acute renal failure.
- In case of renal failure, a characteristic diagnostic sign is a low chlorine content in the blood - less than 95 mmol/l.
- Microscopy data of urinary sediment allows us to judge the nature of the damage. Thus, the presence of non-protein and erythrocyte casts indicates damage to the glomeruli. Brown epithelial casts and loose epithelium indicate. Hemoglobin casts are detected with intratubular blockade.
Since the second stage of acute renal failure provokes severe complications, in addition to urine and blood tests, it is necessary to resort to instrumental methods of analysis:
- , Ultrasound is performed to detect urinary tract obstruction, analyze the size, condition of the kidney, and assess the blood supply. Excretory urography is not performed: radiopaque angiography is prescribed for suspected arterial stenosis;
- chromocystoscopy is prescribed for suspected obstruction of the ureteral orifice;
- radiography thoracic carried out to determine pulmonary edema;
- to assess renal perfusion, isotope dynamic scanning of the kidney is prescribed;
- a biopsy is performed in cases where prerenal acute renal failure is excluded and the origin of the disease has not been identified;
- An ECG is prescribed to all patients, without exception, to detect arrhythmia and signs of hyperkalemia.
Treatment of acute renal failure
Treatment is determined by the type of acute renal failure - prerenal, renal, postrenal, and the degree of damage.
The primary task in the prerenal form is to restore blood supply to the kidney, correct dehydration and vascular insufficiency.
- In the renal form, depending on the etiology, it is necessary to stop taking nephrotoxic drugs and take measures to remove toxins. At systemic diseases the cause of acute renal failure will require the administration of glucocorticoids or cytostatics. For pyelonephritis and infectious diseases, therapy includes antiviral drugs and antibiotics. In conditions of a hypercalcemic crisis, large volumes of sodium chloride solution, furosemide, and drugs that slow down the absorption of calcium are administered intravenously.
- The condition for the treatment of postrenal acute insufficiency is the elimination of obstruction.
The water-salt balance must be corrected. Methods depend on the diagnosis:
- for hyperkalemia above 6.5 mmol/l, a solution of calcium gluconate is administered, and then glucose. If hyperkalemia is refractory, hemodialysis is prescribed;
- To correct hypervolemia, furasemide is administered. The dose is selected individually;
- It is important to observe the total intake of potassium and sodium ions - the value should not exceed daily losses. Therefore, in case of hyponatremia, the volume of fluid is limited, and in case of hypernatremia, sodium chloride solution is administered intravenously;
- the volume of fluid, both consumed and administered intravenously, should generally exceed losses by 400–500 ml.
When the concentration of bicarbonates decreases to 15 meq/l and the blood pH reaches 7.2, acidosis is corrected. Sodium bicarbonate is administered intravenously over 35–40 minutes and then monitored during treatment.
With the non-oliguric form, they try to do without dialysis therapy. But there are a number of indicators for which it is prescribed in any case: symptomatic uremia, hyperkalemia, severe stage of acidemia, pericarditis, accumulation of a large volume of fluid that cannot be removed by medication.
Basic principles of treatment of acute renal failure 
Restorative, polyuric
The stage of polyuria appears only with sufficient treatment and is characterized by a gradual restoration of diuresis. At the first stage, the daily volume of urine is fixed at 400 ml, at the stage of polyuria - more than 800 ml.
At the same time, the relative density of urine is still low, the sediment contains a lot of proteins and red blood cells, which indicates restoration of glomerular functions, but indicates damage to the tubular epithelium. The blood remains high in creatinine and urea.
During the treatment process, potassium levels are gradually restored and accumulated fluid is removed from the body. This stage is dangerous because it can lead to hypokalemia, which is no less dangerous than hyperkalemia and can cause dehydration.
The polyuric stage lasts from 2–3 to 10–12 days, depending on the degree of organ damage and is determined by the rate of restoration of the tubular epithelium.
Activities carried out during the oliguric stage continue during recovery. In this case, the doses of drugs are selected and changed individually depending on the test results. Treatment is carried out against the background of a diet: the consumption of proteins, liquids, salt, and so on is limited.
Recovery stage of acute renal failure 
Recovery
At this stage, normal diuresis is restored, and, most importantly, the products of nitrogen metabolism are removed. If the pathology is severe or the disease is detected too late, nitrogen compounds may not be eliminated completely, and in this case, acute renal failure may become chronic.
At ineffective treatment or too late, the terminal stage may develop, which poses a serious threat to life.
The symptoms of the thermal stage are:
- spasms and muscle cramps;
- internal and subcutaneous hemorrhages;
- cardiac dysfunction;
- bloody sputum, shortness of breath and cough caused by the accumulation of fluid in the lung tissues;
- loss of consciousness, coma.
The prognosis depends on the severity of the underlying disease. According to statistics, with an oliguric course the mortality rate is 50%, with a non-oliguric course - 26%. If acute renal failure is not complicated by other diseases, then in 90% of cases they achieve full recovery kidney function over the next 6 weeks.
Symptoms of recovery from acute renal failure 
Chronic renal failure
CRF develops gradually and represents a decrease in the number of active nephrons - the structural units of the kidney. The disease is classified as chronic if a decrease in functionality is observed for 3 or more months.
Unlike acute renal failure, chronic renal failure is difficult to diagnose even at later stages, since the disease is asymptomatic, and up to the death of 50% of nephrons, it can only be detected during functional load.
There are many causes of the disease. However, about 75% of them are , and .
Factors that significantly increase the likelihood of chronic renal failure include:
- diabetes;
- smoking;
- obesity;
- systemic infections, as well as acute renal failure;
- infectious diseases of the urinary tract;
- toxic lesions - poisons, drugs, alcohol;
- age-related changes.
However, for a variety of reasons, the mechanism of damage is almost the same: the number of active ones gradually decreases, which provokes the synthesis of angiotensin II. As a result, hyperfiltration and hypertension develop in intact nephrons. In the parenchyma, the renal functional tissue is being replaced by fibrous tissue. Due to the overload of the remaining nephrons, a violation of water-salt balance, acid-base, protein, carbohydrate metabolism, and so on gradually arises and develops. Unlike acute renal failure, the consequences of chronic renal failure are irreversible: it is impossible to replace a dead nephron.
The modern classification of the disease distinguishes 5 stages, which are determined by the glomerular filtration rate. Another classification is related to the level of creatinine in the blood and urine. This sign is the most characteristic, and from it you can quite accurately determine the stage of the disease.
The most commonly used classification is related to the severity of the patient's condition. It allows you to quickly determine what measures need to be taken first.
Stages of chronic renal failure 
Polyuric
The polyuric or initial stage of compensation is asymptomatic. Signs of the primary disease prevail, while there is little evidence of kidney damage.
- Polyuria is the excretion of too much urine, sometimes exceeding the volume of fluid consumed.
- Nocturia is an excess of nocturnal diuresis. Normally, urine is released at night in smaller quantities and is more concentrated. Excretion of more urine at night indicates the need for renal-hepatic tests.
- Even at the initial stage, chronic renal failure is characterized by a decrease in the osmotic density of urine - isosthenuria. If the density is above 1.018, CRF is not confirmed.
- Arterial hypertension is observed in 40–50% of cases. Its difference is that in case of chronic renal failure and other kidney diseases, conventional antihypertensive drugs have little effect on blood pressure.
- Hypokalemia can occur at the stage of polyuria with an overdose of saluretics. It is characterized by severe muscle weakness and changes in the ECG.
Sodium wasting syndrome or sodium retention may develop, depending on tubular reabsorption. Anemia is often observed, and it progresses as other symptoms of chronic renal failure increase. This is due to the fact that when nephrons fail, a deficiency of endogenous epoetin is formed.
Diagnosis includes urine and blood tests. The most revealing of them include the assessment of creatinine content in the blood and urine.
Glomerular filtration rate is also a good determining sign. However, at the polyuric stage, this value is either normal - more than 90 ml/min or slightly reduced - to 69 ml/min.
At the initial stage, treatment is mainly aimed at suppressing the primary disease. It is very important to follow a diet with restrictions on the amount and origin of protein, and, of course, salt intake.
Symptoms of the polyuric stage of chronic renal failure 
Stage of clinical manifestations
This stage, also called azotemic or oligoanuric, is distinguished by specific disturbances in the functioning of the body, indicating noticeable damage to the kidneys:
- The most characteristic symptom is a change in urine volume. If at the first stage more fluid was excreted than normal, then at the second stage of chronic renal failure the volume of urine becomes less and less. Oligouria develops - 500 ml of urine per day, or anuria - 50 ml of urine per day.
- Signs of intoxication increase - vomiting, diarrhea, nausea, the skin becomes pale, dry, and in later stages acquires a characteristic jaundiced tint. Due to the deposition of urea, patients are bothered by severe itching; scratched skin practically does not heal.
- Observed severe weakness, weight loss, lack of appetite up to anorexia.
- Due to an imbalance in nitrogen balance, a specific “ammonia” odor appears from the mouth.
- At a later stage, it forms, first on the face, then on the limbs and torso.
- Intoxication and high blood pressure cause dizziness, headaches, and memory impairment.
- A feeling of chills appears in the arms and legs - first in the legs, then their sensitivity decreases. Movement disorders are possible.
These external signs indicate the addition of concomitant diseases and conditions caused by kidney dysfunction to chronic renal failure:
- Azotemia – occurs when there is an increase in nitrogen metabolic products in the blood. Determined by the amount of creatinine in plasma. The uric acid content is not so indicative, since its concentration increases for other reasons.
- Hyperchloremic acidosis is caused by a violation of the mechanism of calcium absorption and is very characteristic of the stage of clinical manifestations; it increases hyperkalemia and hypercatabolism. Its external manifestation is the appearance of shortness of breath and great weakness.
- Hyperkalemia is the most common and most dangerous symptom of chronic renal failure. The kidney is able to maintain the function of potassium absorption until the terminal stage. However, hyperkalemia depends not only on the functioning of the kidney and, when it is damaged, develops initial stages. When the potassium content in the plasma is excessively high - more than 7 meq/l, nerve and muscle cells lose their ability to excitability, which leads to paralysis, bradycardia, central nervous system damage, acute respiratory failure, and so on.
- With a decrease in appetite and against the background of intoxication, a spontaneous decrease in protein intake occurs. However, its too low content in food for patients with chronic renal failure is no less destructive, since it leads to hypercatabolism and hypoalbuminemia - a decrease in albumin in the blood serum.
Another characteristic symptom for patients with chronic renal failure is an overdose of drugs. With chronic renal failure, the side effects of any drug are much more pronounced, and overdose occurs in the most unexpected cases. This is due to kidney dysfunction, which is unable to remove waste products, which leads to their accumulation in the blood.
Diagnostics
The main goal of diagnosis is to distinguish chronic renal failure from other kidney diseases with similar symptoms, and especially from the acute form. To do this, they resort to various methods.
Of the blood and urine tests, the most informative are the following indicators:
- the amount of creatinine in the blood plasma is more than 0.132 mmol/l;
- – a pronounced decrease is 30–44 ml/min. At a value of 20 ml/min, urgent hospitalization is required;
- urea content in the blood is more than 8.3 mmol/l. If an increase in concentration is observed against the background of normal creatinine levels, the disease most likely has a different origin.
Among instrumental methods, ultrasound and x-ray methods are used. A characteristic sign of chronic renal failure is reduction and shrinkage of the kidney; if this symptom is not observed, a biopsy is indicated.
X-ray contrast research methods are not permitted
Treatment
Until the end stage, treatment of chronic renal failure does not include dialysis. Conservative treatment is prescribed depending on the degree of kidney damage and associated disorders.
It is very important to continue treatment of the underlying disease, while eliminating nephrotoxic drugs:
- A mandatory part of treatment is a low-protein diet - 0.8-0.5 g/(kg*day). When the albumin content in the serum is less than 30 g/l, the restrictions are weakened, since with such a low protein content the development of nitrogen imbalance is possible; the addition of keto acids and essential amino acids is indicated.
- When GFR is around 25–30 ml/min, thiazide diuretics are not used. For lower values, they are assigned individually.
- For chronic hyperkalemia, ion-exchange polystyrene resins are used, sometimes in combination with sorbents. In acute cases, calcium salts are administered and hemodialysis is prescribed.
- Correction of metabolic acidosis is achieved by administering 20–30 mmol of sodium bicarbonate intravenously.
- For hyperphosphatemia, substances are used that prevent the absorption of phosphates by the intestine: calcium carbonate, aluminum hydroxide, ketosteryl, phosphocitrile. For hypocalcemia, calcium preparations - carbonate or gluconate - are added to therapy.
Stage of decompensation
This stage is characterized by deterioration of the patient’s condition and the appearance of complications. The glomerular filtration rate is 15–22 ml/min.
- Headaches and lethargy are accompanied by insomnia or, conversely, severe drowsiness. The ability to concentrate is impaired and confusion is possible.
- Peripheral neuropathy progresses - loss of sensation in the arms and legs, up to immobilization. Without hemodialysis, this problem cannot be solved.
- Development of gastric ulcer, appearance of gastritis.
- Chronic renal failure is often accompanied by the development of stomatitis and gingivitis - inflammation of the gums.
- One of the most severe complications of chronic renal failure is inflammation of the serous membrane of the heart - pericarditis. It is worth noting that with adequate treatment this complication is rare. Myocardial damage due to hyperkalemia or hyperparathyroidism is observed much more often. The degree of damage to the cardiovascular system is determined by the degree of arterial hypertension.
- Other common complication– pleurisy, that is, inflammation of the pleural layers.
- With fluid retention, blood stagnation in the lungs and swelling are possible. But, as a rule, this complication appears already at the stage of uremia. The complication is detected by x-ray.
Treatment depends on the complications that arise. Possibly connection to conservative hemodialysis therapy.
The prognosis depends on the severity of the disease, age, and timeliness of treatment. At the same time, the prognosis for recovery is questionable, since it is impossible to restore the functions of dead nephrons. However, the prognosis for life is quite favorable. Since the relevant statistics are not kept in the Russian Federation, it is quite difficult to say exactly how many years patients with chronic renal failure live.
In the absence of treatment, the stage of decompensation passes into the terminal stage. And in this case, the patient’s life can only be saved by resorting to kidney transplantation or hemodialysis.
Terminal
The terminal (last) stage is uremic or anuric. Against the background of retention of nitrogen metabolism products and disruption of water-salt, osmotic homeostasis, etc., autointoxication develops. Dystrophy of body tissues and dysfunction of all organs and systems of the body are recorded.
- Symptoms of loss of sensation in the limbs are replaced by complete numbness and paresis.
- High probability uremic coma and cerebral edema. Against the background of diabetes mellitus, a hyperglycemic coma is formed.
- In the terminal stage, pericarditis is a more frequent complication and is the cause of death in 3–4% of cases.
- Gastrointestinal lesions - anorexia, glossitis, frequent diarrhea. Every 10 patients experience gastric bleeding, which is the cause of death in more than 50% of cases.
Conservative treatment at the terminal stage is powerless.
Depending on the general condition of the patient and the nature of the complications, more effective methods are used:
- – blood purification using an “artificial kidney” device. The procedure is carried out several times a week or every day, has different durations - the regimen is selected by the doctor in accordance with the patient’s condition and the dynamics of development. The device performs the function of a dead organ, so diagnosed patients cannot live without it.
Hemodialysis today is a more affordable and more effective procedure. According to data from Europe and the USA, the life expectancy of such a patient is 10–14 years. Cases have been recorded where the prognosis is most favorable, since hemodialysis prolongs life by more than 20 years.
- - in this case, the role of the kidney, or, more precisely, the filter, is performed by the peritoneum. The fluid introduced into the peritoneum absorbs the products of nitrogen metabolism and is then removed from the abdomen to the outside. This procedure is carried out several times a day, since its effectiveness is lower than that of hemodialysis.
- - the most effective method, which, however, has a lot of limitations: peptic ulcers, mental illness, endocrine disorders. It is possible to transplant a kidney from either a donor or a cadaveric one.
Recovery after surgery lasts at least 20–40 days and requires the most careful adherence to the prescribed regimen and treatment. A kidney transplant can prolong a patient's life by more than 20 years, unless complications arise.
Stages of creatinine and degree of glomerular filtration reduction
The concentration of creatinine in urine and blood is one of the most characteristic hallmarks of chronic renal failure. Another very telling characteristic of a damaged kidney is the glomerular filtration rate. These signs are so important and informative that the classification of chronic renal failure by creatinine or by GFR is used more often than the traditional one.
Classification by creatinine
Creatinine is a breakdown product of creatine phosphate, the main source of energy in muscles. When a muscle contracts, the substance breaks down into creatinine and phosphate, releasing energy. Creatinine then enters the blood and is excreted by the kidneys. The average norm for an adult is considered to be a blood level of 0.14 mmol/l.
An increase in creatinine in the blood causes azotemia - the accumulation of nitrogen breakdown products.
Based on the concentration of this substance, 3 stages of disease development are distinguished:
- Latent - or reversible. Creatinine levels range from 0.14 to 0.71 mmol/L. At this stage, the first uncharacteristic signs of chronic renal failure appear and develop: lethargy, polyuria, and a slight increase in blood pressure. There is a decrease in the size of the kidney. The picture is typical for a condition when up to 50% of nephrons die.
- Azotemic - or stable. The level of the substance varies from 0.72 to 1.24 mmol/l. Coincides with the stage of clinical manifestations. Oligouria develops, headaches, shortness of breath, swelling, muscle spasms, etc. appear. The number of working nephrons decreases from 50 to 20%.
- Uremic stage - or progressive. Characterized by an increase in creatinine concentration above 1.25 mmol/l. Clinical signs are pronounced, complications develop. The number of nephrons is reduced to 5%.
By glomerular filtration rate
Glomerular filtration rate is a parameter used to determine the excretory capacity of an organ. It is calculated in several ways, but the most common involves collecting urine in two hourly portions, determining minute urine output and creatinine concentration. The ratio of these indicators gives the value of glomerular filtration.
GFR classification includes 5 stages:
- Stage 1 – with a normal level of GFR, that is, more than 90 ml/min, signs of renal pathology are observed. At this stage, for cure, sometimes it is enough to eliminate the existing negative factors - smoking, for example;
- Stage 2 – slight decrease in GFR – from 89 to 60 ml/min. At both stages 1 and 2, it is necessary to adhere to a diet, accessible physical activity and periodic observation by a doctor;
- Stage 3A – moderate decrease in filtration rate – from 59 to 49 ml/min;
- Stage 3B – marked decrease to 30 ml/min. At this stage, drug treatment is carried out.
- Stage 4 – characterized by a severe decrease – from 29 to 15 ml/min. Complications appear.
- Stage 5 – GFR is less than 15 ml, the stage corresponds to uremia. The condition is critical.
Stages of chronic renal failure according to glomerular filtration rate 
Kidney failure is a severe and very insidious syndrome. In a chronic course, the first signs of damage to which the patient pays attention appear only when 50% of the nephrons, that is, half of the kidneys, have died. Without treatment, the likelihood of a favorable outcome is extremely low.
End-stage chronic renal failure ceased to be a death sentence from the moment blood purification devices appeared and began to be improved, replacing renal functions. But even with effective and complete treatment, the life expectancy of a person in the terminal stage of chronic renal failure is limited to the next 10–15 years. No doctor can say exactly how long a person with non-functioning kidneys will live.
Periods of end-stage chronic renal failure
The reasons for the significant deterioration in the functional state of the kidneys with the formation of chronic renal failure are a sharp decrease in the number of nephrons in the parenchyma. Most often, their death occurs against the background of a complicated course of chronic kidney diseases, in which proper treatment was not carried out or there were deep anatomical and functional damage to the kidneys.
Regardless causal factors, the terminal stage of chronic renal failure is divided into several periods:
Determining the exact condition of the patient is required to choose treatment tactics: in periods 1 and 2, there are still opportunities to use effective methods of therapy. In the 3rd and 4th periods, when irreversible changes occur in vital organs, it is extremely difficult to hope for positive dynamics of treatment.
Basic treatment methods
All therapeutic measures in the terminal stage of chronic renal failure are carried out in a hospital setting and are divided into conservative methods and surgical ones. The vast majority of patients will require all possible treatment options for renal failure, which will be used in stages.
Conservative treatment
The main methods used in all patients in the last stage of chronic renal failure include diet therapy and antitoxic effects on the blood.
Dialysis
Any conservative treatment methods for chronic renal failure, especially in the terminal stage, are not effective enough. It is optimal to use modern treatment methods that almost completely replace lost kidney function. For chronic renal failure, the main type of therapy is dialysis, the essence of which is to pass fluid through a special filter to separate and remove harmful substances. Dialysis can be used at any stage of the terminal stage.
- Hemodialysis. For direct blood purification in the treatment of chronic renal failure, an “artificial kidney” device is needed. The technique involves taking blood from a sick person, purifying it through a machine filter and returning it back to the body’s vascular system. The effectiveness is much higher, so it is usually necessary to carry out a procedure lasting 5-6 hours 2-3 times a month.
Kidney transplant
Surgical treatment for kidney transplantation is carried out only in periods 1 and 2 of the clinical course of end-stage chronic renal failure. If at the examination stage the doctor discovered severe and irreversible changes in vital organs (heart, liver, lungs), then there is no point in doing a kidney transplant. In addition, surgery is contraindicated for severe pathologies of the endocrine system, mental illness, stomach ulcers and the presence of acute infection anywhere in the body.
The selection of a donor kidney is of great importance. The best option is a close relative (mother, father, brother or sister). If there are no relatives, you can try to get donor organ from a suddenly deceased person.
Medical technologies make it possible to perform a kidney transplant without any particular difficulties, but the main thing is not the operation at all, but further treatment to prevent rejection of the transplanted organ. If everything went well and without complications, then the prognosis for life is favorable.
Any treatment for terminal chronic renal failure has the main goal of restoring basic renal functions. In the initial period of the terminal stage of the disease, it is best to perform a kidney transplant, especially if all vital organs are fully functioning. For cardiopulmonary and liver failure Your doctor will prescribe different dialysis options. A prerequisite for therapy is adherence to a diet and regular detoxification courses. The result of complex therapeutic effects will be the longest possible preservation of human life.
Stage 4 Chronic Kidney Failure (CKF)
Stage 4 chronic renal failure is a serious stage of kidney disease with a glomerular filtration rate of 15-30 ml/min. Severe decline in kidney function will cause systemic symptoms. Patients at this stage, on the one hand, should pay special attention to diet and lifestyle changes in order to manage the disease situation and not burden the kidneys, and on the other hand, receive treatment to improve the kidney situation and avoid threatening complications.
As kidney function deteriorates, metabolites will be able to accumulate in the bloodstream and cause a medical condition called Anemia. Because the kidneys cannot produce erythropoietin effectively and the hormone stimulates the production of blood cells, patients with stage 4 kidney failure will become anemic. The kidneys regulate electrolyte balance, and in stage 4 kidney failure it was common for patients to suffer from high sodium, high phosphorus, low calcium, high sodium, etc. High potassium will cause arrhythmia, high sodium threatens fluid retention and will increase blood pressure, and elevated phosphorus will cause sore bones.
Symptoms of stage 4 chronic kidney failure mainly include:
* Weakness. Feeling tired is a result of stage 4 anemia symptom.
* Change in urination. Urine may be foamy and the foam persists for a long time. This is a sign of increased protein in the urine. Blood in the urine will cause the urine color to be dark orange, brown, tea-colored, or red. The person may pass more or less urine, or go to the toilet frequently at night.
* Difficulty falling asleep. Itchy skin, restless legs or muscle cramps may keep the sufferer awake and have difficulty falling asleep.
* Nausea. Chronic kidney failure may cause vomiting or nausea.
* Lack of appetite. The patient has no desire to eat and often complains of a metallic or ammonia taste in the mouth.
* Cardiovascular diseases . In stage 4 chronic renal failure, various factors, including high blood pressure, water and salt retention, anemia and toxic substances, will increase the patient's risk of heart failure, arrhythmia, myocardial damage, etc.
* Symptoms in the nervous system. Early symptoms mainly include insomnia, poor concentration, and memory loss. In some cases, patients suffer from tingling, numbness, coma, insanity and others.
Patients with stage 4 usually require blood testing creatinine. hemoglobin, calcium, potassium and calcium in order to find out how the kidneys work and how to reduce the risk of complications. After determining the test result, the doctor will advise the patient on the best treatment option. Because diet is a necessary part of treatment, so a dietician will also be necessary for treatment. And the dietitian will examine the test result and give the patient his own dietary plan. A proper nutrition plan helps maintain kidney function and overall health.
Some of the basic dietary tips for stage 4 kidney failure mainly include the following:
Calculate protein intake. Proteins are sources of nutrition for the human body. However, too much protein is harmful because it will produce more nitrogenous waste. Taking 0.6 grams of protein per kilogram per day is beneficial when your glomerular filtration rate falls below 25, or approximately 25% of your kidney function remains. You should ask your doctor how much protein is available per day and remember that at least half of the protein comes from high-quality sources like egg whites, lean meats, fish, etc.
Limiting sodium intake. Too much sodium can cause retention of large liquids. And this will lead to swelling and shortness of breath in the person. A person in stage 4 kidney failure should avoid eating processed foods and prepare a lunch with low sodium or sodium ingredients. Most diets start with a goal of 1500-2000 mg per day or as recommended by your doctor.
Maintain a healthy body weight. If you want to maintain a healthy weight by burning calories, now you need to exercise regularly.
Cholesterol intake. Replace saturated fats unsaturated fats and make a diet generally low in fat. This may help reduce the risk of heart disease.
Other tips. You should limit potassium intake if laboratory results are above the normal range. If the palm has too much fluid content, it will limit fluid intake. Symptoms of fluid retention mainly include swelling in the legs, arms, face, high blood pressure and shortness of breath.
In order to prolong kidney health, patients in stage 4 kidney failure should take medications recommended by their doctor to control blood pressure, anemia and other situations. People in stage 4 are likely to further lose kidney function and end up on dialysis. Apart from a basic management plan to control the progress of the disease, proper treatment will help improve renal function from a poor position to a better position and therefore dialysis will not be necessary. And this will be accomplished by combining Western medicine and traditional Chinese medicine.
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There may be questions for your attention:
Kidney failure in men
Kidney failure is considered a complex problem even with the availability of modern treatments. This is a potentially reversible, sudden-onset kidney disorder or failure. This insidious disease destroys not only the kidneys, but the body as a whole. The disease affects both sexes regardless of age. But, renal failure in men differs in the nature of development and manifestations from a similar condition in women. This is due to the characteristics of male and female physiology.
Characteristic differences in the development of PN in men
- Prostate cancer;
- Excessive alcohol consumption;
- Tobacco smoking;
- Drug use.
With untimely and poor-quality treatment, renal failure progresses and leads to serious disorders in the functioning of all organs and systems. Intoxication of the body develops, metabolism is disrupted, which leads to irreversible consequences. The trend in the number of men suffering from kidney failure is increasing annually by 10-12%.
Kidney failure concept
This is a terminal pathology in which the function of the kidneys is partially or completely lost and they cease to form, filter and excrete urine. As a result, disturbances in water-salt, acid-base and osmotic homeostasis develop in the body, which leads to disruption of the functioning of all organs and systems. In the clinic, the disease is distinguished into two forms - acute and chronic.
Acute renal failure
Causes of acute renal failure
Causes development of surge arresters in men are diverse. They can be divided into three groups and their corresponding forms:
Symptoms of acute renal failure
Stages of acute renal failure
In the clinical picture of acute renal failure, there are 4 clearly defined stages.
Initial
This stage is characterized by symptoms caused by the factors that caused acute renal failure. It can mildly manifest itself in general malaise, the gradual development of intoxication syndrome, accompanied by abdominal pain, nausea, and pale skin.
Oligoanuric
The main sign of the development of this stage is a sharp decrease in urine output, or its complete absence. The total amount of urine usually does not exceed 500 ml per day. Urine bloody, with a lot of sediment. The patient's condition worsens sharply during the first three days. Characteristic blood indicators are proteinuria, azotemia, hyperphosphatemia, hyperkalemia, hypernatemia, and acidosis. If pulmonary edema develops, shortness of breath and moist rales occur. This indicates self-poisoning of the body, the signs of which are lethargy, drowsiness, swelling throughout the body, adynamia, etc.
Pathological conditions also develop in other organs: pericarditis, uremic gastroenterocolitis, pancreatitis, hepatitis, pneumonia, sepsis. The duration of this stage can be from several hours to several days. A longer duration of this period of acute renal failure may indicate the development of complications from the kidneys or other organs and systems.
Diuretic
This is the recovery stage, which is divided into the early diuresis phase and the polyuria phase. Daily diuresis gradually increases, indicating restoration of renal concentration function. At this stage, the patient's condition may be accompanied by cellular dehydration. But as the kidneys recover, the danger of dehydration and associated complications passes. The volume of urine excreted returns to normal and reaches 2.5 liters. Together with the kidneys, the functions of other organs are restored. The recovery period lasts up to 2.5 -3 weeks.
Recovery
This stage is quite long and can last up to several months. The functions of the kidneys and other organs are fully restored.
Diagnostics of acute renal failure
ARF should be differentiated from acute urinary retention due to the presence of common symptoms. Anamnesis is of great importance in the diagnosis of acute renal failure. His information will help determine the presence of diseases that can cause anuria or the fact of poisoning of the body. Descriptions of pain in the lumbar region help the doctor determine the form of acute renal failure - renal, postrenal, etc. The absence of urine in the bladder suggests acute renal failure. If it contains at least a small amount of it, then it is examined, which makes it possible to clarify the diagnosis.
Kidney ultrasound is the most informative diagnostic method
IN diagnostic purposes The biochemistry of blood plasma is carried out for the content of urea, creatinine, electrolytes and the acid-base balance is revealed.
To diagnose postrenal acute renal failure, instrumental, ultrasound and x-ray examinations of the kidneys are performed. These methods make it possible to determine the degree of preservation of kidney function, their size and structure.
The diagnostic results allow us to determine treatment issues for acute renal failure.
Treatment of acute renal failure
Treatment methods for acute renal failure are selected depending on the stage of the disease.
ARF prognosis
Acute renal failure is terminal condition, and its outcome depends on timely and high-quality treatment. With a favorable outcome, full restoration of renal function occurs in 35-40% of cases, partial restoration– in 10-15% of cases, and for 1-3% of patients who have suffered acute renal failure, hemodialysis is constantly required.
Chronic renal failure
Chronic renal failure syndrome is the gradual death of the cellular structures of the kidney - nephrons as a result of progressive kidney pathology. The functional renal tissue is replaced by connective tissue and the volume of the organ decreases.
The causes of chronic renal failure are often glomerulonephritis and pyelonephritis in chronic form; diabetes; renal malformations, vascular diseases, systemic diseases.
The mechanism of development of chronic renal failure is associated with structural changes in the kidney parenchyma. As a result of dysfunction of the glomeruli and tubules, there is a decrease in the number of functioning nephrons, damage to the circulatory renal system, inflammatory edema and sclerosis of connective tissue structures. All this leads to disruption of metabolic processes.
Symptoms of chronic renal failure
Signs of chronic kidney failure appear depending on the stage of the disease.
Diagnostics
The diagnosis of chronic renal failure is made through a set of measures:
Hemodialysis machine used as replacement therapy for renal failure
Treatment of chronic renal failure
Each stage of chronic renal failure has its own treatment strategy, taking into account all diagnostic test indicators.
Replacement therapy for chronic renal failure is hemodialysis and peritoneal dialysis.
Peritoneal dialysis is used to cleanse the blood at home by the patient himself.
Hemodialysis is a hardware extrarenal method of blood purification, which allows you to remove toxins from the body and normalize water and electrolyte balance. The procedure is carried out in a hospital setting at least 3 times a week, each procedure lasting at least 4 hours.
The procedure for purifying blood using peritoneal dialysis involves filling the abdominal cavity with dialysate solution through a catheter. In the abdominal cavity, an exchange takes place between the solution and the patient’s blood. As a result, toxic substances and water are removed through the catheter. The solution remains in the cavity for several hours. The advantages of this method are that the patient does not have to be constantly dependent on the hemodialysis unit. He performs the entire procedure independently. For monitoring, he visits the dialysis center monthly. The method is most often used while waiting for a kidney transplant.
Nutrition for renal failure syndrome
Following a diet for kidney failure is important, as certain types of foods can worsen its progression. It is developed taking into account the stage and severity of the disease, the presence of exacerbations or complications. A diet is prescribed with restriction of animal proteins, salt, and phosphorus. The quantity and quality of the dietary composition of food is compiled by a nutritionist together with the attending physician. It is recommended to replace animal proteins with plant proteins, mainly soy proteins. Standards for the consumption of vegetable fats and carbohydrates are also established.
Kidney transplant surgery is performed at the fifth stage of development of renal failure
16.08.2011, 15:07
The patient is 73 years old, stage 4 chronic renal failure due to polycystic kidney disease and chronic pyelonephritis in the acute stage. Received treatment in a hospital. Then he was discharged, a nurse came home, gave him IVs (reosorbilact 200, every other day glucose 400 with calcium gluconate, at the end of the IVs Lasix), I gave him intramuscular injections - Loraxone. He also took sorbifer and dufolac.
Indicators at discharge:
UAC: 08/09/11 Hb - 64.4 g\l, er.2.18Х10\l, CPU-0.98, Leu - 9.7Х10\l,
e - 1, p-10, s-64, l-22, m-3, ESR - 75 mm/h, Ht-19%
OAM- sour, 1010, protein - 0.033, sugar - none, leuk - 1-3v p\zr
Blood sugar - 4.8 mol/l, Urea - 13.5 mmol/l, creatinine - 492.5
total protein - 65 g/l, total bilirubin: 11.8, direct - 3.6, indirect - 8.2, ALT - 1.0, AST - 0.35
Yesterday his temperature had already dropped to 37.2, but today it rose above 38, the nurse who administered the IV gave him an injection of analgin with diphenhydramine. His speech began to disappear. An ambulance was called. The ambulance doctors said that he had cerebral edema from intoxication, but they wouldn’t take him to the hospital without a referral from the clinic and they left.
I urgently called a doctor from the clinic. She said that he would not last more than a couple of days, and it was better to leave him at home. But still. Having responded to my requests for a referral just in case he suddenly started to experience pain, she gave me a referral to urology.
What to do? Maybe we should still try to fight and send him to the hospital? Or is there really no point?
He will not be given hemodialysis, since according to the order of our Ministry of Health, either 184 or 185, we do not provide hemodialysis to persons over 65 years of age.
What to do? Insist on hospitalization? Or do as they advise 0 to leave everything as it is?
Is there a chance to save him? Or is it all useless?
17.08.2011, 09:03
The patient has indications for hospitalization. An ambulance in such a situation does not need a referral from the clinic. Speculation about the number of days and age is also not a reason to refuse help to a person. If you repeatedly fail to provide assistance, please ask for a written refusal, with which you can contact the management of the ambulance substation, clinic and law enforcement agencies. Most likely, instead of a written refusal, the patient will be hospitalized.
17.08.2011, 17:26
Thank you for your answers. The patient was hospitalized last night. I called an ambulance, he was taken straight to neurology with a suspicion of a stroke, but they checked there - there was no stroke, and he was admitted to urology.
Despite the fact that he has gotten better, he drinks and urinates in a jar himself, although he does not speak, he only nods, today I was offered to take him home so that he would die at home. They politely suggested this and said: “We are not kicking him out under any circumstances, but nothing can be done, his kidneys have failed. Well, we will rinse him with IVs and water.” And she objected that they prescribed rheosorbilact and other drugs. which we immediately bought. Then the head of the department told me that yes, we will rinse with rheosorbilact.
I asked if we take him home and he starts to have severe pain, what will we do? To which I was told that they would prescribe strong painkillers, but that there should be no pain at all.
Question: can there be pain?
In any case, they decided to leave him in the hospital for now, but what if he gets better? Moreover, they still do tests there, and the medical staff, who are still better than me, give injections.
P.S. Where do you get information about such orders?
That's what the doctor from the hemodialysis department told me.
We also went there, and they told us that the queue was huge, since we only have hemodialysis, and that this is not an easy procedure, and some elderly people die right on dialysis. This is true?
By the way, our patient has a strong heart, yesterday the ambulance did a cardiogram, his heart is normal.
I asked the doctor - why did this happen? Could this be from an overdose of the same glucose, or Loraxone? But he replied that no, it was because of uremia.
17.08.2011, 17:41
Regarding the scans, unfortunately, the fresh ones remained in the medical card; the doctor took them from the clinic and then wrote out a referral to the hospital.
That's what it is, in July, after that he was in the hospital again, this is the third time.
For the first time this year, he spent 20 days in hospital, came out with... feeling good and indicators. I walked around the city myself, felt so good that I gave up everything and didn’t go to the doctors until June, when I started feeling bad again. In June, the temperature began to rise, and he was hospitalized with a temperature of under 40.
He was discharged with good indicators - see the extract. But I had a fever every other day, ate little, and lost weight.
When I pick up the card, I can show you other statements.
I apologize, this is not a scan, the scanner did not work, I just had to take a photo of the statement.
17.08.2011, 17:51
Here is another ultrasound scan that was taken in February.
Personal information (full name, address, and doctors’ names I erase).
17.08.2011, 22:26
In accordance with the information provided: 1) in June. I don’t see any signs of active pyelonephritis. CKD stage 5 (GFR 12-14 ml/min) 2) taking into account the sharp deterioration of the condition after 1.5 months. after discharge, accompanied by fever and progression of renal failure, there is an assumption about the possibility of acute complicated pyelonephritis (associated with suppuration of cysts?) and aggravation of chronic renal failure in connection with this (such as the “acute renal failure on chronic renal failure” option). With this option, the treatment tactics are somewhat different than for terminal CKD without active nephropathy and adequate, timely treatment usually retains the hope of avoiding an unfavorable outcome and even a return to earlier stages of CKD. Hemodialysis in this situation is a maintenance therapy as part of complex treatment and, after eliminating the source of inflammation, can, in some cases, be discontinued.
In the absence of active pyelonephritis, stage 5 CKD requires adequate treatment of chronic renal failure, which was not prescribed to the patient (recommended by the nephrologist).
17.08.2011, 23:27
Don’t rush to pick him up from the hospital; insist on further examination and treatment. Ask the manager and chief physician to clarify the situation with dialysis. In the absence of data for acute pyelonephritis in urology, he basically has nothing to do now. Does the hospital have a nephrology department? In the city?
18.08.2011, 14:31
Thanks for answers.
No, there is no specialized nephrology department either in the hospital or in the city. There is only a urology department, where they took him, and a hemodialysis department, where they didn’t take him.
Today he feels better - his speech has been restored, he understands everything and speaks coherently. They give him IVs - the same ones we did at home according to their instructions. For example, today we did calcium, and then glucose. He drinks and eats, but walks on his own. Maybe he has a disorder digestive system because of antibiotics? Maybe he should get some Motilium?
Tests showed that his sugar was normal, but there was a lack of protein in his blood, so he was prescribed albumin. We went to the blood transfusion station, bought this albumin and brought it. We have to buy all our medications ourselves.
I spoke on the phone with a neurologist, a professor. He did not look at the patient because he was away, and tried to describe all the symptoms. He said that from what I was describing, it did sound like cerebral edema due to kidney failure. And that the patient will either recover, can recover, or die.
I read on the Internet that even with hemodialysis, strokes are possible as complications. As well as other central nervous system disorders, such as
1) acute cerebrovascular accidents during hemodialysis or immediately after it; 2) chronic dementia on regular PG; 3) subclinical manifestations of brain disorders in adequately treated patients; 4) acute disorders brain functions, not related to dialysis, but resulting from uremia or occurring in previously stable patients.
It's all sad. :(I used to think that hemodialysis is a panacea. That patients with chronic kidney disease on hemodialysis live for years. But here it is...
18.08.2011, 17:15
He will not be given hemodialysis, since according to the order of our Ministry of Health, either 184 or 185, we do not provide hemodialysis to persons over 65 years of age.
Order of the Ministry of Health of Ukraine dated May 11, 2011 No. 280 ([Only registered and activated users can see links]) "On approval of the standard and unified clinical protocols for the provision of medical assistance in the specialty "nephrology"
Contraindications before HD treatment:
- The misfortune of the sick man.
- Agonal camp.
- Dementia (diagnosed by a psychiatrist).
- An incurable evil process.
Translation:
Contraindications to HD treatment:
- Disagreement of the patient.
- Agonal state.
- Dementia (diagnosed by a psychiatrist).
- Incurable malignant process.
The order does not say anything about the age of 65 years.
19.08.2011, 12:08
The order does not say anything about the age of 65 years.
As I was told, this is not an order from the Ministry of Health, but an order from the Ministry of Health of the Autonomous Republic of Crimea. We are in Crimea.
My father got worse. Yesterday he spoke normally and smiled, today he began to twitch all over under the IV, shake, his reactions slowed down again. We were told there was no hope. We gave up and will take him home. At least we will be close at home all the time.
Why did he feel so bad again? They don't tell us anything. Only that the kidneys are not working.
Another question: do all people with chronic renal failure end up this sad? He has a sister with the same problem, plus one of her kidneys was removed long ago.
There are even younger people in the family, but also with polycystic disease, and so far without renal dysfunction.
21.08.2011, 05:00
Don’t rush to pick him up from the hospital; insist on further examination and treatment. Ask the manager and chief physician to clarify the situation with dialysis.
You were right. He stayed at home for just over a day.
At first there was nothing. Yesterday morning he even got up on his own and then ate a little. But he practically drank. Then he began to feel the urge to urinate, but the urine did not pass. He suffered. We called an ambulance, they put a catheter on him, but there was no urine. They assumed that he had an adenoma, since it was difficult for them to pass through the catheter. Is this really possible? He was in urology so many times and they didn’t check? Definitely no one did an ultrasound of his prostate. When I took him to a paid nephrologist, she advised me to do this ultrasound, and I made an appointment, but he was already feeling so bad that he didn’t want to go anywhere, he put it off. And then it was too late. The ambulance crew gave him an injection for blood pressure, his blood pressure was 170/100. Over time. after they left, apparently when the injection took effect, he was able to excrete 50 grams of urine and calmed down. I even tried to sleep. But after an hour and a half, everything started all over again - a terrible urge to urinate, with no result. He moaned and screamed. It was terrible. He didn’t want to drink, he spat out the water that we tried to pour into his mouth. He was shaking wildly... But when blood appeared in his stool, we called an ambulance again and took him to the hospital. They debated for a long time whether to take it or not. In the end they took it. They said that they would do IVs and everything else.
The ambulance doctor said that since his kidneys weren’t working, he couldn’t be given IV drips; there would be brain swelling. But he suffered so much that I thought that brain swelling and death were better than such suffering.
At the hospital they told us that the blood in the stool was probably because the intoxication had already penetrated into the stomach...
I called the hemodialysis department and asked for help. But the doctor on duty told me that he could not make such a decision himself, since the decision on hemodialysis was made by a commission.. When he was brought to the hospital, they called a doctor from the intensive care unit, he looked and said that he could not do anything, since the patient I need an artificial kidney. But...
It's horrible....
When they tried to persuade us to take him out of the hospital, we were told that he would die peacefully. No one told us that this terrible urge to urinate would be possible and that he would suffer so much.
Why weren't we told this? Did you just want to get rid of him? Or is this really atypical for chronic kidney disease? And how can we alleviate his suffering if he continues to suffer? What should you ask doctors to do?
During the 24 hours that we took him home, we received such psychological trauma, my blood pressure is 180/100, I feel sick, I can’t eat or drink. But I still continue to hope for a miracle that he will get better, and that he will survive, and live without suffering for another month or two...
21.08.2011, 17:39
21.08.2011, 21:21
It is impossible to say anything concrete without the results of the latest extract. Can you post it?
Yes, I'm posting the latest one. Sorry for looking like this, I took a picture and can't scan it.
I was at his hospital today. He keeps shouting: “Hurry, hurry!” They offer him a jar, but there is no urine. A catheter, the doctor said, he didn’t let me install it. They put an IV in, he tore it off. They tied him to the bed, lightly, but so that he wouldn’t fall. The nanny is on duty next to him.
They gave him the painkiller ketarol, but he still shakes and groans.
I asked to give him a strong painkiller, like Promedol, but they told me that it would kill him, and they are not killers. What if he has prostate cancer?
What should I do?
The doctor said he has two days left. I asked: “Do everyone die like this from chronic kidney disease?” He answered yes.
21.08.2011, 21:37
The extract is extremely meager. Did you have an ultrasound of the bladder? The fact that the catheter did not obtain urine does not always mean that the bladder is empty. It’s possible that they didn’t make it into the bubble. The presence of such unbearable urges is alarming. In anuria they should not be present. Or is this the result of a violation? brain activity(that is, false urges). It's a pity that this is not reflected in the statement. You can determine whether or not you have simple cancer by taking blood for PSA and palpating the gland with your finger through the rectum. I don’t see any connection with the refusal of pain relief and probable (???) prostate cancer. Is he skinny or not? Is your stomach enlarged? Blood in the stool is an indication for examination by a surgeon. What is the cause of severe pain is also not clear (or, again, groaning and anxiety are the result of impaired consciousness).
P.S. It’s not so important now, but the list of appointments in the extract, except for item 15, doesn’t mean anything. :(
P.P.S. It was worth talking in the hemodialysis department not with the person on duty, but with the manager or chief physician.
21.08.2011, 23:22
C acting The head of the hemodialysis department talked. Unsuccessfully. She stated that in order to do hemodialysis with them, he had to be in their department many times, but he had never been there. They didn't take it because...
Do you think there is anything else that can be done to save him?
He is terribly thin, and has been for a long time. When I took him to see the chief nephrologist, she said that he needed to be fed 5 times a day, so we fed him. But it was no use, he didn't gain weight.
In February, when he stayed in this department for 20 days, he managed to gain weight to 48 kg, he was admitted with 42. Now he is probably less than 40 kg.
His belly is not enlarged, on the contrary, it is stuck. What does this mean?
Tomorrow we will try to go to the toxicology department at another hospital, they say they also have hemodialysis for emergency patients.
Maybe call the Ministry of Health and try to get hemodialysis through him in the hemodialysis department? But they will start saying again that he has contraindications, I’m afraid that you won’t be able to prove anything there. We have an anti-corruption department under the Ministry of Health, where you can report a refusal to provide assistance. I'll try to call there tomorrow.
21.08.2011, 23:34
22.08.2011, 00:14
The presence of such unbearable urges is alarming. In anuria they should not be present. Or is it the result of a disturbance in brain activity (that is, false urges).
Shouldn’t it be the same for prostate adenoma?
Anuria must be accompanied by thirst. nausea, vomiting, he doesn’t have all this.
Even when he was walking, moving, he complained that urinating was uncomfortable.
22.08.2011, 00:16
No visible abdominal enlargement lower parts despite the fact that the person is thin, he speaks against acute urinary retention. It is likely that his urge to urinate is false. Only a full-time specialist can say more accurately whether he has a mental disorder or not.
Thank you.
Regarding the “anti-corruption department”: you can start with a conversation with the head physician, ask for orders and show where it is written that assistance can only be provided to someone who was previously in the department (???), and not to someone who is actually in it needs it now. Ask for a written refusal to provide him with assistance and, with this written refusal, apply to higher authorities with a complaint.
Thanks, I'll try.
22.08.2011, 14:37
In the hemodialysis department they refused to take the patient, and they also refused to accept the patient. They said that they should be called from the urology department where he is lying. Also acting The head of the department said that all patients with chronic kidney disease in the thermal stage moan like this.
The urology department suggested a CT scan of the head to rule out the possibility of stroke and other lesions.
Since, as the attending physician said, the patient has a strange pain syndrome and increased sensitivity. If there is no stroke, only then will they call a commission from the hemodialysis department to consider the possibility of dialysis. Then they will have to write a refusal, and with this refusal they can already complain.
It's just time, time is running out...
The only thing: when the misfortune happened to our patient, it was last Tuesday, we were told that he had 2 days left. But he felt better. Then, the truth got worse again, and we were again told that this was the end. But the end does not come, he slowly eats from a spoon. He doesn't scream like that anymore, he just moans. Doesn't throw out IVs.
22.08.2011, 15:02
Let them do a CT scan of the head if they need it to organize adequate care for the patient. There are indications for this.
22.08.2011, 21:39
Everything is over. he died.
Early this morning we went to the toxicology department,
here in this
But there we were sent back to the hemodialysis department, which I wrote about in a previous post.
23.08.2011, 16:48
:(:(:(Please accept my condolences. Can this topic be closed?
25.08.2011, 19:03
Thank you.
I would also like to show a fragment of the posthumous epicrisis.
And ask you, could something be done? Save him?
There, in the epicrisis, there was a typo (the patient), apparently they took the form of another deceased.
When my mother took the epicrisis, she was treated. the doctor said that it was his fault, that he should have done a CT scan earlier. And that in the morning, on the day of death, he invited the neurologist again, and that one. Having examined my dad, she said that he seemed to have it. There was a cerebral hemorrhage, which is why they ordered a CT scan. There was dried blood on his lips. Even when they buried him, she was barely visible, although they washed him in the morgue. What could it be?
And on the death certificate they wrote briefly: polycystic disease, uremia
25.08.2011, 19:18
There was no autopsy?
Unfortunately, without seeing the patient, it is impossible to reliably say about the presence or absence of neurological symptoms caused by a stroke. It is also virtually impossible to differentiate the signs of cerebrovascular accident from intoxication in uremia. In the presented honey. The neurological status is also not described in the documents. This is the opinion of a urologist, I will also ask neurologists to comment, perhaps they will correct or complement me.
25.08.2011, 19:30
There was an autopsy. They wrote briefly: polycystic disease, uremia - this is in the medical report. The lady who issued the medical report told my mother that he died of kidney disease. But the conclusion bears the signature of a male pathologist - I was in such a state that I could not talk to him myself. I'm going to call the morgue and talk to him.
As for neurologists, that would be good. for them to comment.
If only I had known that it was a stroke, I would have sent him to intensive care, I have friends there, I also personally know the head of the neurology department. I called him when dad became ill and lost his speech. He was away and could not personally examine the patient. But he said that according to my descriptions, it looks like cerebral edema.
Then they told me that if the kidneys were not working, then it was impossible to give him IVs - there would be brain swelling, but he was given IVs all the time.
The symptoms were as follows: at first he seemed to fall into a doze, this happened on the 16th, he stopped recognizing everyone, stopped talking, and began to defecate on himself (he did this before his death), underlip it swelled and fell off. But the pressure and temperature were normal. Therefore, the first ambulance that arrived did not take him to the hospital. stating that since the pressure is normal, they won’t take me to the hospital without a referral. While I was getting a referral from a therapist, while I was calling an ambulance again, consciousness and speech returned to him. After
He was taken to neurology, but then the neurologist, after examining him, said that it was not a stroke, and he was admitted to urology. That’s where they tried to push everyone out, which is what I wrote about at the beginning of the topic. At first he felt better there, he understood everything and spoke. But quietly, and sometimes slowly. Then it got worse. And we were persuaded to take him home. We took him, and at first he seemed better. But a painful urge to urinate began. However, during the day he sat down himself, then got up and ate a little. But then he fell. Then I asked him not to interject yet, he understood everything and nodded. But then those terrible urges to urinate began, he shouted: “Hurry, hurry,” we substituted a jar, but there was no urine, and this continued until his death.... When it got really bad, we called an ambulance again and sent him away to the hospital, we hoped that they would help. But they didn't help...
27.08.2011, 22:54
Hello. I really sympathize with your grief.
Unfortunately, based on the information available, I can’t say anything definite. There are no clear focal neurological symptoms that would clearly indicate that a stroke has occurred. But sometimes these symptoms are minimal and are visible only to an experienced clinician upon examination. In addition, the post-mortem epicrisis did not describe a stroke. If an autopsy was performed, all diseases that could lead to death should be described.
Maybe you will be reassured by the fact that dried blood on the lips is not characteristic feature cerebral hemorrhages. This could be a consequence of biting the tongue or lip, both voluntary and involuntary - you described episodes of excitement when the patient was tossing about in bed, even being fixed.
29.08.2011, 13:19
I have another question for the urologist: my aunt, who also suffers from polycystic disease and chronic kidney disease, refuses to believe that dad died as a result of polycystic disease. She believes that he had prostate cancer, which is why he screamed like that, says that she was in nephrology and urology many times, and saw people die from kidney disease. As if they don’t scream like that, she further says that such patients are usually swollen. And dad was very thin, literally dried out, and yellow. In addition, his hip hurt badly for the last 2 months. An aunt says that a friend of hers had a husband who died of prostate cancer. and that he also had pain in his hip, it radiated there. At the very beginning, he was diagnosed with inflammation of the sciatic nerve when it started. And we injected him with sodium diclofenac, which made him even worse. Only when the temperature rose, he was taken to the hospital (this was in June), there they gave him drips of rheosorbilact and augumetin, the pain in the kidneys went away, but the temperature rose every other day. Then he was simply discharged home, apparently they thought that everything was useless.
Maybe my aunt is just trying to persuade herself this way because she’s afraid that she, too, will die so terribly? Or is she right? She also motivates by the fact that her urea and creatinine levels were worse than his, but she lives and walks. He says that he does not believe the doctors, that they all conspired to protect themselves from a possible lawsuit from relatives. Or is there some truth to her suspicions? They didn’t take blood for PSA, nor did they do an ultrasound of the prostate. When he was still normal, I signed him up for a prostate ultrasound twice, but he didn’t want to go, it was hard for him, although I would have driven him by car, but he still delayed it, saying - after. I should have not listened and dragged him, of course. When I dragged him to that nephrologist, he didn’t want to go to him either.
We believed that since he was in urology so many times, they would have diagnosed an adenoma. Back in early August, when I brought him to the nephrologist, and she asked how he urinated, he replied that it was uncomfortable. But this also happens as a result of kidney disease?
And one more thing: my aunt says that when a person lies down, his kidneys don’t hurt, they only hurt when he moves. And he was sick. The pain was at night, he did not sleep well, so then he slept during the day. She is right? Or is it just that her only kidney is still working and she doesn’t understand?
29.08.2011, 15:17
I have another question for the urologist:
1. my aunt, who also suffers from polycystic disease and chronic kidney disease, refuses to believe that dad died as a result of polycystic disease. She believes that he had prostate cancer, which is why he screamed like that, says that she was in nephrology and urology many times, and saw people die from kidney disease. As if they don’t scream like that, she further says that such patients are usually swollen. And dad was very thin, literally dried out, and yellow.
2. In addition, his hip was very painful for the last 2 months. An aunt says that a friend of hers had a husband who died of prostate cancer. and that he also had pain in his hip, it radiated there. At the very beginning, he was diagnosed with inflammation of the sciatic nerve when it started. And we injected him with sodium diclofenac, which made him even worse. Only when the temperature rose, he was taken to the hospital (this was in June), there they gave him drips of rheosorbilact and augumetin, the pain in the kidneys went away, but the temperature rose every other day. Then he was simply discharged home, apparently they thought that everything was useless.
3. Maybe the aunt is just trying to persuade herself this way, because she is afraid that she, too, will die so terribly? Or is she right? She also motivates by the fact that her urea and creatinine levels were worse than his, but she lives and walks.
4. He says that he does not believe the doctors, that they all conspired to protect themselves from a possible lawsuit from relatives. Or is there some truth to her suspicions? They didn’t take blood for PSA, nor did they do an ultrasound of the prostate. When he was still normal, I signed him up for a prostate ultrasound twice, but he didn’t want to go, it was hard for him, although I would have driven him by car, but he still delayed it, saying - after. I should have not listened and dragged him, of course. When I dragged him to that nephrologist, he didn’t want to go to him either.
5. We believed that since he was in urology so many times, they would have diagnosed an adenoma. Back in early August, when I brought him to the nephrologist, and she asked how he urinated, he replied that it was uncomfortable. But this also happens as a result of kidney disease?
6. And one more thing: my aunt says that when a person lies down, his kidneys don’t hurt, they only hurt when he moves. And he was sick. The pain was at night, he did not sleep well, so then he slept during the day. She is right? Or is it just that her only kidney is still working and she doesn’t understand?
1. The behavior of patients with uremia is different and is explained by the toxic effect of nitrogenous waste on the central nervous system.
2. Patients with metastases to the spine may have similar symptoms, but they can also occur in the absence of metastases (and cancer) - due to inflammation or strangulation of a root disc herniation.
3. We may not have her data.
4. Ultrasound of the prostate is not as important as digital rectal examination and PSA. But this is for the living. Now there is the result of an autopsy - data on prostate cancer, especially with distant metastases, not found.
5. The reasons may be different, for example, neurological disorders, prostatitis, etc.
6. The kidneys don’t care whether a person sits, stands or lies; if the outflow of urine is impaired, the pain will be constant. Pain in the lumbar region associated with movement, most likely of a vertebrogenic nature (associated with the spine).
29.08.2011, 15:24
I see a different problem: why a patient with polycystic disease, gradually decompensating, has never been on hemodialysis. You can try to explain this situation so that the aunt and other patients are not left without help if necessary.
29.08.2011, 18:21
2. Patients with metastases to the spine may have similar symptoms, but they can also occur in the absence of metastases (and cancer) - due to inflammation or strangulation of a root disc herniation.
He definitely didn't have a hernia. When the pain started, back in June, I took him for an X-ray of his spine. I took him to a private clinic, they had better equipment, and the picture was clearer. He had an x-ray of his spine in 2 projections, everything was normal there.
4. Ultrasound of the prostate is not as important as digital rectal examination and PSA.
He said that a urologist saw him in the hospital. In front of me, the nephrologist asked if he had been examined by a urologist, if he had a finger inserted there, he replied that yes, and that it was painful. Does this mean that there was definitely no cancer? In the post-mortem epicrisis they wrote - grade 1 adenoma. Is this an initial adenoma?
The kidneys don’t care whether a person is sitting, standing or lying down; if the outflow of urine is disrupted, the pain will be constant. Pain in the lumbar region associated with movement, most likely of a vertebrogenic nature (associated with the spine).
Thank you, that's what I thought. He was constantly in pain, but when severe pain began in June, he could not walk; he fell from pain literally after five steps. That’s when we first treated him for supposedly inflammation of the sciatic nerve (this diagnosis was given to him by both the local therapist and the emergency doctor), then we did an x-ray. And only then, when his temperature rose to 39C, he was taken to the hospital by ambulance.
I see a different problem: why a patient with polycystic disease, gradually decompensating, has never been on hemodialysis. You can try to explain this situation so that the aunt and other patients are not left without help if necessary.
But, unfortunately, all the doctors gave me an answer to this question, citing that order of the Ministry of Health of the Autonomous Republic of Crimea. The fact that supposedly in old age there are a lot of contraindications to hemodialysis, etc. In fact, because the queue is for the young, and the old are no longer being saved. Our resuscitator told me the same thing. that they don’t do dialysis on the orders of the elderly. When I said that if they had told me earlier, I would have done dialysis for him for a fee, he answered me: “And how much would it cost you? If he had to do hemodialysis every other day?” Yes, I wouldn’t have pulled it off in a day. I would pull at most 2-3, well 4 times a month, no more :(
As for my aunt, she immediately told me that she had been in nephrology many times and had also tried to get dialysis, and that it was useless. If she needs dialysis, now I already know where it is done in Sevastopol. Her whole body is now covered in bruises. My father developed such bluish spots before his death. Is this also related to the kidneys?
31.08.2011, 23:51
I sympathize with your grief, belle08. However, for a correct understanding of the situation, as well as for choosing the right tactics in the future, I consider it necessary to clarify a number of points for you:
1. Chronic renal failure requires early, according to special program, treatment under the supervision of a nephrologist (which, on the one hand, “pushes back” the need to start dialysis to a later date, and on the other hand, helps to start dialysis in a timely manner).
2. The issue of starting hemodialysis is decided long before the deterioration of health, taking into account the dynamics of blood tests in persons under constant supervision of a nephrologist (a therapist or urologist competent in these matters).
3. Patients are enrolled in hemodialysis for life (or until a kidney transplant), with procedures usually performed at least 3 times a week for an average of 4 hours. In remote areas, peritoneal dialysis may be used under certain conditions and in the absence of contraindications.
4. In Russia, due to the lack of the required amount of equipment, the dialysis service (more correctly, the renal replacement therapy service) is unevenly developed. In your region, it is probably poorly developed, so there is a queue for dialysis, which should be formed accordingly (see point 2)
5. The lack of necessary equipment in such regions leads to a queue and therefore patients who suddenly develop advanced chronic renal failure (uremia) will not be able to get dialysis, because The queue for the next (already prepared for dialysis) patient with chronic renal failure (you can’t connect two people to one machine) will move back.
6. The level of creatinine and urea in any patient (and especially in an elderly person) does not reflect the true severity of chronic renal failure, and in your situation (IMHO) apparently an additional factor was the rate of progression of chronic renal failure.
8. And finally, the clinical picture of uremia (end-stage chronic renal failure) is so diverse that “auntie’s observation experience” and conclusions based on it are, to put it mildly, incorrect. I find no reason not to believe the autopsy results.
07.09.2011, 22:04
6. The level of creatinine and urea in any patient (and especially in an elderly person) does not reflect the true severity of chronic renal failure, and in your situation (IMHO) apparently an additional factor was the rate of progression of chronic renal failure.
How then to monitor CP?
What tests should I take to know exactly the condition?
7. Polycystic kidney disease has a number of features that can lead to loss of sodium and water (which, unfortunately, was not tested in the hospital), against the background of which the administration of NSAIDs (diclofenac) could sharply worsen the course of chronic renal failure up to anuria.
Could antibiotics also lead to this?
The main neurologist, to whom I brought my father in early August, said that he was dehydrated and exhausted, so she recommended salting his food, giving more water, and feed him 5 times a day, increasing portions, adding protein, up to one egg a day (earlier his diet excluded protein - only 40 grams per week), she assured that in a month it would be better. We did everything as she said, and his temperature began to rise, then we were admitted back to the hospital, where they gave him IVs and injected him with Loraxone. He got worse there, and we took him home, and did the same IVs and Loraxone at home, hired a good nurse, and fed him 5 times a day. He began to look better and felt better, we were able to increase the portions of food from “children’s” to normal, the temperature began to drop, and was already 37.2 when he suddenly stopped watching TV in the evening, then stopped smoking, didn’t smoke for a day, and in the morning he had a seizure. that cerebral edema.... After which he lived for a week....
06.11.2011, 18:51
History repeats itself. Aunt is my father’s sister, 5 years younger, one kidney, polycystic disease, chronic renal disease. Creatinine 740, urea 47.
They tried to get hemodialysis for her, her husband even wrote an application addressed to the Minister of Health. But she was admitted to nephrology and is being treated with IVs. To the same doctor in the department who promised me that my father would feel better in a month, but he didn’t get better in a month... She inspired my aunt that hemodialysis should not be done if the kidney is working at least a little, otherwise after dialysis it will work will stop on its own. My aunt told me about this while lying under a drip, in an edifying tone, with the underlying reason that she didn’t need hemodialysis at all. I didn’t argue with her so as not to upset her.
As I understand it, if my aunt’s kidney really continues to strain, then the drips will be able to lower her creatinine a little, and she will feel better. Bye. If you're lucky. I don’t know my aunt’s GFR, as I understand it, they haven’t measured it yet, they haven’t done a reberg test. Aunt sacredly believes the doctor and everything she says.
I’m beginning to suspect that that doctor is kept in this position because she brilliantly knows how to set up patients so that they do not require hemodialysis, moreover, they shy away from it. And thereby saving money on hemodialysis.
06.11.2011, 22:27
07.11.2011, 01:16
Unfortunately, you either did not read post 32 carefully, or in September 2011, your aunt’s situation was already critical. Now no droppers will help (GFR is around 5 ml.min).
Doctor, I not only read it, I remember. And I insisted on hemodialysis. And she explained to her aunt and her aunt’s husband what and how. And she asked my aunt not to agree to IV drips, because given that she has such indicators, as I understand it, drips can cause cerebral edema in her. :(The aunt’s husband and the aunt first tried to get through to the head physician of the hospital, then they went to the Ministry of Health, and there, in the public reception room, the aunt’s husband wrote a statement. After which the aunt was sent to nephrology, to Dr. Lopatina (I’ll give her last name). And Dr. Lopatina I put my aunt in nephrology and is treating her with IVs. My aunt believes her. What can I do? My aunt also made a complaint against me, saying that the doctor was offended that they went to the Ministry of Health. My aunt states that they have a young woman there The lady lies with creatinine 800, and nothing, she lives and will live for a long time.
What can I do? The doctor probably has a great gift for persuading patients.
It's a shame that my aunt had the opportunity to get hemodialysis in another city, the relatives made an agreement. But my aunt believed the nephrologist, chief nephrologist of the ARK-S.A. Lopatina, and told me that I didn’t understand anything. :(
P.S. I also have polycystic kidney disease, and when I was offered to see Dr. Lopatina, I flatly refused. So I will never go to her, because I don’t trust her. Now I know that she should have put my father on hemodialysis and he would have lived or died in peace.
07.11.2011, 06:04
Believe me, this advice was painfully suffered even for the developed regions of the Russian Federation. Because dialysis is not a panacea; Patients with end-stage renal failure (for example, as a result of familial polycystic disease) require a kidney transplant. And the waiting list for a kidney transplant, alas, is long...
07.11.2011, 15:30
Alas, doctors may have very different reasons for refusing dialysis... The simplest is lack of space.
Draw conclusions for yourself personally - this is more important for you, since you are young and still have time. You can, for example, spend it on getting a good education and moving to a permanent place of residence somewhere closer to developed medicine....
Thank you, of course. 3 years ago I returned from the USA, where I had permanent residence, to be close to my father. In the state where I lived, dialysis was free for everyone.
I still think that rather than running for my own sake, it is better to fight locally to make dialysis available to everyone. And I, due to my profession, will try to put all my efforts into this.
As for kidney transplantation, there is no donor institution in Ukraine yet (as doctors told me), but kidneys are transplanted for money. So I think I will look into this issue more closely if the need arises.
What is it - kidney failure is serious functional disorder kidneys, which leads to water, electrolyte and acid-base imbalance in the body.
Renal failure is characterized by a sharp decrease in the amount of urine excreted by the kidneys, up to complete absence During a long time.
As a result, the functioning of all internal human organs is disrupted. Lack of adequate and timely treatment can lead to irreversible kidney damage, which will become a real threat to human life.
Causes of kidney failure
There are two forms of kidney failure: acute and chronic. They differ in their manifestations and treatment methods. Acute renal failure (ARF) sometimes becomes chronic.
ARF can occur as a result of shock of various origins, the harmful effects of poisons and toxic substances, infections, kidney diseases, taking medications. ARF has a classification that is differentiated depending on the manifestations of the syndrome.
Thus, acute renal failure is divided into:
Chronic renal failure (CRF) most often develops due to kidney disease and urinary tract, as well as endocrine and cardiovascular diseases. This condition is characterized by the slow death of kidney tissue until its complete destruction.
Moreover, in chronic renal failure there are four stages of its development:
Both acute and chronic renal failure have their own symptoms and manifestations.
Acute renal failure develops gradually, going through several stages in its development, which are characterized by a certain set of symptoms.
There are four stages of acute renal failure:
1) For the first, initial stage of acute renal failure characterized by mild symptoms. Clinical manifestations relate to the cause of acute renal failure, for example, symptoms of poisoning due to exposure to a poison or symptoms of an underlying disease. Thus, the primary specific symptom of acute renal failure is only a decrease in the amount of urine excreted. This condition can last for several days, during which signs of intoxication may appear with abdominal pain, mild swelling and pale skin.
2) Second stage is marked by the further development of oliguria up to anuria - the complete inability of the kidneys to produce urine. Symptoms become more severe due to the accumulation of urea in the blood. So, arrhythmia appears. hypertension. tachycardia. Sometimes convulsions occur. A person’s reactions are inhibited and drowsiness occurs. In addition, extensive swelling appears, including swelling of the optic disc. From the gastrointestinal tract (GIT), the patient may suffer from nausea, vomiting and diarrhea.
3) The third stage is recovery. The person begins to feel better due to the fact that kidney function gradually returns to normal. Symptoms of intoxication disappear, normal functioning of all internal organs is restored. The recovery period depends on the degree of kidney damage, the causes of acute renal failure and the adequacy of treatment.
4) Sometimes experts highlight fourth stage. by which we mean the entire range of processes aimed at restoring the functionality and condition of the kidneys to their original parameters. In general, the recovery period can last several months.
Symptoms of chronic renal failure
Symptoms also develop in stages. Chronic renal failure is characterized by gradual kidney damage with slowly progressing symptoms. So, a person can suffer from chronic renal failure for several months or even years.
1) For the latent stage of chronic renal failure characterized by mild symptoms. Clinical manifestations are largely related to the underlying disease that caused the development of chronic renal failure. As chronic renal failure develops, a person may begin to suffer from increased fatigue, which will be especially noticeable during high physical activity, weakness, drowsiness and dry mouth, which will increase the person’s need for drinking water. Polyuria may develop - an increase in the volume of urine excreted by the kidneys.
2) Next stage- stage of clinical manifestations, the name of which speaks for itself. Functional failures in the functioning of the kidneys appear, which is expressed in a sharp decrease in the amount of urine excreted. This entails a change in blood composition, which will be visible in tests. Weakness and general fatigue of the patient progress. Constant dry mouth and thirst appear. From the gastrointestinal tract, symptoms such as nausea, stomach pain, and bad breath appear. Diarrhea and vomiting are possible. Due to a severe decrease in appetite, a person can lose significant weight. Neurological disorders also appear, which are expressed in insomnia, headaches and apathy. There may be problems with the cardiovascular system, which will result in arrhythmia and tachycardia. In addition, pain in bones and joints may occur.
3) The next stage is the stage of decompensation, which is characterized by the addition of additional secondary symptoms. Since a person with chronic renal failure in most cases has severe sore throats, pharyngitis and acute respiratory diseases, complications may develop, including pneumonia and pulmonary edema. In addition, a number of other complications may occur, the occurrence of which depends on the person’s condition.
4) The last stage of chronic renal failure is marked by many symptoms that greatly impair a person’s quality of life. The final stage is characterized by a general decrease in mood combined with neurological symptoms. Severe swelling appears, the skin acquires a yellowish tint. Urine that is not excreted by the kidneys is excreted through sweat, which explains the constant unpleasant odor from a person suffering from chronic kidney disease.
From the gastrointestinal tract, vomiting, heartburn and diarrhea can be observed. Severe intoxication of the body occurs, which leads to functional disorders in the work of other organs. Thus, a person’s production of necessary hormones decreases, his overall immunity decreases, which leads to the development of various diseases that a person is not able to cope with on his own. Without treatment, changes in internal organs eventually become irreversible, leading to death.
Treatment of kidney failure
Acute renal failure is a reversible process. Treatment consists primarily of eliminating the cause of acute renal failure, which will avoid further negative effects on the kidneys. This is achieved through intensive therapy. Normal functions kidneys are returned thanks to hemodialysis or peritoneal dialysis, which allows the kidneys to fully recover. The prognosis for acute renal failure is favorable in most cases.
Treatment chronic renal failure depends on the general condition of the person, on the causes of chronic renal failure and on the advanced state of the disease. Therapy is carried out aimed at treating the root cause of chronic renal failure, as well as aligning all metabolic processes in the human body.
Therapy should also be aimed at slowing the progression of kidney damage. The success of treatment largely depends on the person, that is, on how responsibly he approaches the implementation of all the doctor’s instructions. At the last stage of chronic renal failure, regular dialysis or transplantation of a healthy kidney is necessary.
The prognosis of chronic renal failure is quite favorable if treatment is started in the initial stage or stage of clinical manifestations. The prognosis of end-stage renal failure depends on the possibility of kidney transplantation. If such an opportunity exists, then this gives a person a chance for a significant extension of life, which will be practically no different from the life of healthy people.
Which doctor should I contact for treatment?
If, after reading the article, you suspect that you have symptoms characteristic of this disease, then you should consult a urologist.
Prognosis for life with end-stage chronic renal failure
End-stage chronic renal failure ceased to be a death sentence from the moment blood purification devices appeared and began to be improved, replacing renal functions. But even with effective and complete treatment, the life expectancy of a person in the terminal stage of chronic renal failure is limited to the next 10–15 years. No doctor can say exactly how long a person with non-functioning kidneys will live.
Periods of end-stage chronic renal failure
The reasons for the significant deterioration in the functional state of the kidneys with the formation of chronic renal failure are a sharp decrease in the number of nephrons in the parenchyma. Most often, their death occurs against the background of a complicated course of chronic kidney diseases, in which proper treatment was not carried out or there were deep anatomical and functional damage to the kidneys.
Regardless of the causative factors, the terminal stage of chronic renal failure is divided into several periods:
Determining the exact condition of the patient is required to choose treatment tactics: in periods 1 and 2, there are still opportunities to use effective methods of therapy. In the 3rd and 4th periods, when irreversible changes occur in vital organs, it is extremely difficult to hope for positive dynamics of treatment.
Basic treatment methods
All therapeutic measures in the terminal stage of chronic renal failure are carried out in a hospital setting and are divided into conservative methods and surgical ones. The vast majority of patients will require all possible treatment options for renal failure, which will be used in stages.
Conservative treatment
The main methods used in all patients in the last stage of chronic renal failure include diet therapy and antitoxic effects on the blood.
- Detoxification. Terminal chronic renal failure is characterized by a sharp deterioration in the functioning of the kidneys to cleanse the body of toxins and harmful substances formed in the process of life. Basic treatment involves mandatory blood detoxification. The doctor will prescribe various options for IVs, with the help of which it will be possible to partially remove toxic substances, replacing the work of diseased kidneys.
- Peritoneal dialysis. The inner surface of the abdomen consists of peritoneum, which is a natural filter. It is this property that is used for constant and effective dialysis. With the help of surgery, a special catheter tube is placed inside the abdomen, which contains a dissolving liquid (dialysate). Blood flowing through the vessels of the peritoneum releases harmful substances and toxins that are deposited in this dialysate. The solvent fluid needs to be changed every 6 hours. Changing the dialysate is technically simple, so the patient can do it independently.
- Hemodialysis. For direct blood purification in the treatment of chronic renal failure, an “artificial kidney” device is needed. The technique involves taking blood from a sick person, purifying it through a machine filter and returning it back to the body’s vascular system. The effectiveness is much higher, so it is usually necessary to carry out a procedure lasting 5-6 hours 2-3 times a month.
- Prerenal, that is, the disease is caused by heart failure, collapse, shock, severe arrhythmias, a significant reduction in circulating blood volume (possibly in case of blood loss).
- Renal, in which the death of the renal tubules is caused by the action of heavy metals, poisons, alcohol, drugs or due to insufficient blood supply to the kidney; sometimes the cause is acute glomerulonephritis or tubulointerstitial nephritis.
- Postrenal, that is, as a result of acute bilateral blockage of the ureters due to urolithiasis.
- Signs of renal failure in the initial phase: decreased amount of urine, decreased blood pressure, increased heart rate.
- The second phase (oliguric) consists of reducing the amount of urine or until its production stops. The patient's condition becomes serious, as almost all body systems are affected and a complete metabolic disorder occurs, which threatens life.
- The third phase (restorative or polyuric) is characterized by an increase in the amount of urine to a normal level, but it almost does not remove any substances from the body except salts and water, so in this phase there remains a danger to the patient’s life.
- Renal failure of the 4th degree consists in the normalization of urine output, kidney function returns to normal after 1.5-3.5 months.
- Take lingonberry leaves, chamomile, motherwort herb, string flowers, dandelion and violet, half a teaspoon each. This collection is poured into a glass boiled water, leave for about 1 hour and take a third of a glass 5 times a day.
- Second recipe: mix mint, St. John's wort, lemon balm, calendula 1 tbsp. l. Pour into a saucepan herbal mixture Add 2 cups boiled water and bring to a boil. Pour the prepared infusion into a thermos and leave overnight. Take 100 ml per day.
- Treatment folk remedies renal failure includes the use watermelon rinds having a diuretic effect. Take 5 tbsp. l. chopped watermelon rinds per liter of water. You need to fill the crusts with water, leave for an hour and take several times throughout the day.
- Pomegranate peel and rose hips also have a mild diuretic effect. Take them in equal parts and pour two glasses of boiled water. Leave in a warm place for half an hour and take up to 2 glasses per day.
- It is necessary to limit protein intake to 65 g per day, depending on the phase of kidney disease.
- The energy value of food increases due to increased consumption of fats and carbohydrates.
- The diet for kidney failure boils down to eating a variety of fruits and vegetables. In this case, it is necessary to take into account the content of proteins, vitamins and salts in them.
- Proper culinary processing of products is carried out to improve appetite.
- The amount of sodium chloride and water entering the body is regulated, the amount of which affects the presence of swelling and blood pressure indicators.
Dialysis
Any conservative treatment methods for chronic renal failure, especially in the terminal stage, are not effective enough. It is optimal to use modern treatment methods that almost completely replace lost kidney function. For chronic renal failure, the main type of therapy is dialysis, the essence of which is to pass fluid through a special filter to separate and remove harmful substances. Dialysis can be used at any stage of the terminal stage.
Kidney transplant
Surgical treatment for kidney transplantation is carried out only in periods 1 and 2 of the clinical course of end-stage chronic renal failure. If at the examination stage the doctor discovered severe and irreversible changes in vital organs (heart, liver, lungs), then there is no point in doing a kidney transplant. In addition, surgery is contraindicated for severe pathologies of the endocrine system, mental illness, stomach ulcers and the presence of acute infection anywhere in the body.
The selection of a donor kidney is of great importance. The best option is a close relative (mother, father, brother or sister). If there are no relatives, you can try to get a donor organ from a person who suddenly died.
Medical technologies make it possible to perform a kidney transplant without any particular difficulties, but the main thing is not the operation at all, but further treatment to prevent rejection of the transplanted organ. If everything went well and without complications, then the prognosis for life is favorable.
Any treatment for terminal chronic renal failure has the main goal of restoring basic renal functions. In the initial period of the terminal stage of the disease, it is best to perform a kidney transplant, especially if all vital organs are fully functioning. For cardiopulmonary and liver failure, the doctor will prescribe various dialysis options. A prerequisite for therapy is adherence to a diet and regular detoxification courses. The result of complex therapeutic effects will be the longest possible preservation of human life.
Kidney failure: how to treat, what diet and nutrition
Kidney failure is pathological condition kidneys, in which they do not fully perform their work to the required extent as a result of any disease. This process leads to a change in the constancy of the body’s self-regulation, and as a result, the functioning of its tissues and organs is disrupted.
Renal failure can occur in acute (ARI) and chronic (CRF) forms.
The causes of kidney failure vary depending on the form of the disease. There are several reasons that cause acute renal failure:
The causes of chronic renal failure are considered chronic glomerulonephritis and pyelonephritis, systemic diseases, urolithiasis disease, neoplasms in the urinary system, diseases with impaired metabolism, vascular changes(high blood pressure, atherosclerosis) and genetic diseases.
Symptoms of the disease
Signs of renal failure depend on the severity of changes in renal function, the duration of the disease and the general condition of the body.
There are four degrees of acute renal failure:
Signs of kidney failure in people who have a chronic form include a significant decrease in the amount of working kidney tissue, which leads to azotemia (increased levels of nitrogenous substances in the blood). Since the kidneys can no longer cope with their work, these substances are eliminated in other ways, mainly through the mucous membranes of the gastrointestinal tract and lungs, which are not designed to perform such functions.
Renal failure syndrome quickly leads to the development of uremia, when self-poisoning of the body occurs. There is an aversion to eating meat, attacks of nausea and vomiting, a regular feeling of thirst, a feeling of muscle cramps and bone pain. A jaundiced tint appears on the face, and the smell of ammonia is felt when breathing. The amount of urine excreted and its density are greatly reduced. Kidney failure in children follows the same principles as in adults.
Complications of the disease
End-stage renal failure is caused by a complete loss of kidney function, which causes toxic products to accumulate in the patient's body. Terminal renal failure provokes complications such as gastroenterocolitis, myocardial dystrophy, hepatorenal syndrome, and pericarditis.
Hepatorenal failure means progressive oliguric renal failure secondary to liver disease. With hepatorenal syndrome, vasoconstriction occurs in the cortical region of the kidneys. This syndrome in cirrhosis is considered as the last stage of development of the disease, which leads to the retention of water and sodium ions.
Diagnostic methods
Diagnosis of kidney failure includes determining the amount of creatinine, potassium and urea in the blood, as well as constant monitoring of the amount of urine excreted. Ultrasound, radiography and radionuclide methods can be used.
To diagnose chronic renal failure, a complex of advanced biochemical studies of blood and urine, filtration rate analysis, and urography are used.
Treatment with medications
Treatment of renal failure is carried out in the intensive care unit or intensive care wards of a hospital. In case of the slightest complications, you should immediately contact medical care. Today it is possible to treat patients with acute renal failure using an artificial kidney device, while renal function is restored.
If treatment is started promptly and carried out in full, the prognosis is usually favorable.
During therapy, impaired metabolic processes are treated, diseases that aggravate chronic renal failure are identified and treated. At a later stage, continuous hemodialysis and kidney transplantation are required.
Medicines for renal failure are used to reduce metabolic processes: anabolic hormones - testosterone propionate solution, methylandrostenediol. To improve renal microcirculation, you need to use trental, chimes, troxevasin and complamin for a long time. To stimulate urine output, a glucose solution with insulin or diuretics from the furosemide group is prescribed. If observed high concentration nitrogen in the blood, then the gastrointestinal tract is washed with a solution of sodium bicarbonate, due to which nitrogenous wastes are removed. This procedure is carried out on an empty stomach, before meals, once a day.
Antibiotics for renal failure are used in reduced doses, since their rate of elimination is significantly reduced. The degree of chronic renal failure is taken into account and the dose of antibiotics is reduced to 2 or 4 times.
Treatment of the disease with traditional methods
How to treat kidney failure without the use of antibiotics and other medications is described in the recipes below.
Principles of diet therapy for renal failure
Diet for kidney failure plays an important role - it is necessary to adhere to a diet low in protein and sodium chloride, and to exclude drugs that have a toxic and damaging effect on the kidneys. Nutrition for kidney failure depends on several general principles:
Sample diet menu for kidney failure:
First breakfast: boiled potatoes – 220g, one egg, sweet tea, honey (jam) – 45g.
Lunch: sweet tea, sour cream – 200g.
Dinner: rice soup - 300g (butter - 5-10g, sour cream - 10g, potatoes - 90g, carrots - 20g, rice - 20g, onions - 5g and tomato juice - 10g). For the second course, serve vegetable stew - 200g (from carrots, beets and rutabaga) and a glass of apple jelly.
Dinner: milk porridge from rice - 200g, sweet tea, jam (honey) - 40g.
Prognosis for the disease
With timely and adequate treatment, the prognosis for acute renal failure is quite favorable.
In the chronic version of the disease, the prognosis depends on the stage of the process and the degree of renal dysfunction. If renal function is compensated, the prognosis for the patient’s life is favorable. But in the terminal stage, the only options to maintain life are continuous hemodialysis or transplantation of a donor kidney.
Stage 4 Chronic Kidney Failure (CKF)
Stage 4 chronic renal failure is a serious stage of kidney disease with a glomerular filtration rate of 15-30 ml/min. Severe decline in kidney function will cause systemic symptoms. Patients at this stage, on the one hand, should pay special attention to diet and lifestyle changes in order to manage the disease situation and not burden the kidneys, and on the other hand, receive treatment to improve the kidney situation and avoid threatening complications.
As kidney function deteriorates, metabolites will be able to accumulate in the bloodstream and cause a medical condition called Anemia. Because the kidneys cannot produce erythropoietin effectively and the hormone stimulates the production of blood cells, patients with stage 4 kidney failure will become anemic. The kidneys regulate electrolyte balance, and in stage 4 kidney failure it was common for patients to suffer from high sodium, high phosphorus, low calcium, high sodium, etc. High potassium will cause arrhythmia, high sodium threatens fluid retention and will increase blood pressure, and elevated phosphorus will cause sore bones.
Symptoms of stage 4 chronic kidney failure mainly include:
* Weakness. Feeling tired is a result of stage 4 anemia symptom.
* Change in urination. Urine may be foamy and the foam persists for a long time. This is a sign of increased protein in the urine. Blood in the urine will cause the urine color to be dark orange, brown, tea-colored, or red. The person may pass more or less urine, or go to the toilet frequently at night.
* Difficulty falling asleep. Itchy skin, restless legs or muscle cramps may keep the sufferer awake and have difficulty falling asleep.
* Nausea. Chronic kidney failure may cause vomiting or nausea.
* Lack of appetite. The patient has no desire to eat and often complains of a metallic or ammonia taste in the mouth.
* Cardiovascular diseases. In stage 4 chronic renal failure, various factors, including high blood pressure, water and salt retention, anemia and toxic substances, will increase the patient's risk of heart failure, arrhythmia, myocardial damage, etc.
* Symptoms in the nervous system. Early symptoms mainly include insomnia, poor concentration, and memory loss. In some cases, patients suffer from tingling, numbness, coma, insanity and others.
Patients with stage 4 usually require blood testing creatinine. hemoglobin, calcium, potassium and calcium in order to find out how the kidneys work and how to reduce the risk of complications. After determining the test result, the doctor will advise the patient on the best treatment option. Because diet is a necessary part of treatment, so a dietician will also be necessary for treatment. And the dietitian will examine the test result and give the patient his own dietary plan. A proper nutrition plan helps maintain kidney function and overall health.
Some of the basic dietary tips for stage 4 kidney failure mainly include the following:
Calculate protein intake. Proteins are sources of nutrition for the human body. However, too much protein is harmful because it will produce more nitrogenous waste. Taking 0.6 grams of protein per kilogram per day is beneficial when your glomerular filtration rate falls below 25, or approximately 25% of your kidney function remains. You should ask your doctor how much protein is available per day and remember that at least half of the protein comes from high-quality sources like egg whites, lean meats, fish, etc.
Limiting sodium intake. Too much sodium can cause retention of large liquids. And this will lead to swelling and shortness of breath in the person. A person in stage 4 kidney failure should avoid eating processed foods and prepare a lunch with low sodium or sodium ingredients. Most diets start with a goal of 1500-2000 mg per day or as recommended by your doctor.
Maintain a healthy body weight. If you want to maintain a healthy weight by burning calories, now you need to exercise regularly.
Cholesterol intake. Replace saturated fats with unsaturated fats and make a diet low in fat overall. This may help reduce the risk of heart disease.
Other tips. You should limit potassium intake if laboratory results are above the normal range. If the palm has too much fluid content, it will limit fluid intake. Symptoms of fluid retention mainly include swelling in the legs, arms, face, high blood pressure and shortness of breath.
In order to prolong kidney health, patients in stage 4 kidney failure should take medications recommended by their doctor to control blood pressure, anemia and other situations. People in stage 4 are likely to further lose kidney function and end up on dialysis. Apart from a basic management plan to control the progress of the disease, proper treatment will help improve renal function from a poor position to a better position and therefore dialysis will not be necessary. And this will be accomplished by combining Western medicine and traditional Chinese medicine.
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Renal failure and anuria
Acute renal failure is a condition in which there is a sudden cessation or a very sharp decrease in the function of both kidneys or a single kidney. As a result of the development of this condition, it appears azotemia . which increases rapidly, and severe water and electrolyte disturbances are also noted.
In the same time anuria is a serious condition of the body in which the flow of urine into the bladder completely stops, or no more than 50 ml of urine enters during the day. A person suffering from anuria has no urination and no urge to urinate.
What's happening?
In the pathogenesis of the disease, the leading factor is impaired blood circulation in the kidneys and a decrease in the level of oxygen delivered to them. As a consequence, there is a violation of all important functions kidney - filtration . excretory . secretory . As a result, the content of nitrogen metabolism products in the body sharply increases, and metabolism is seriously disturbed.
In approximately 60% of cases, signs of acute renal failure are observed after surgical operations or injuries. About 40% of cases of the disease occur during the treatment of patients in a hospital. IN in rare cases(approximately 1-2%) this syndrome develops in women during pregnancy .
Distinguish acute And chronic stage of renal failure. The clinical picture of acute renal failure can develop within several hours. If the diagnosis is made in a timely manner and all measures have been taken to prevent this condition, then kidney function is fully restored. Presentation of treatment methods is carried out only by a specialist.
There are several types of acute renal failure. Prerenal renal failure develops due to acute disruption of blood flow in the kidneys. Renal renal failure is the result of damage to the renal parenchyma. Postrenal renal failure is a consequence of a sudden disruption of the outflow of urine.
Causes
The development of acute renal failure occurs during traumatic shock, which damages tissue. Also, this condition develops under the influence of reflex shock, a decrease in the amount of circulating blood due to burns, and large blood loss. In this case, the state is defined as shock bud . This occurs in serious accidents, severe surgical interventions, wounds, myocardial infarction . when transfusion of incompatible blood.
A condition called toxic kidney . manifests itself as a result of poisoning with poisons, intoxication of the body with medications, alcohol abuse, substance abuse, and radiation.
Acute infectious kidney - consequences of serious infectious diseases - hemorrhagic fever . leptospirosis . This can also occur during severe infectious diseases, in which dehydration quickly develops.
Acute renal failure also develops as a result of urinary tract obstruction. This happens if the patient’s tumor grows, there are stones, thrombosis, embolism of the renal arteries is observed, or a ureteral injury occurs. In addition, anuria sometimes becomes a complication of acute pyelonephritis and acute glomerulonephritis .
During pregnancy, acute renal failure is most often observed in the first and third trimesters. In the first trimester, this condition may develop after abortion . especially if carried out under non-sterile conditions.
Renal failure also develops as a result of postpartum hemorrhage, as well as preeclampsia in last weeks pregnancy.
There are also a number of cases where it is not possible to clearly determine the reasons why the patient develops acute renal failure. Sometimes this situation occurs when several different factors influence the development of the disease.
Symptoms
Initially, the patient does not show direct symptoms of renal failure, but signs of the disease that leads to the development of anuria. These could be signs of shock, poisoning, or direct symptoms of the disease. Further symptoms in children and adults manifest themselves as a decrease in the amount of urine excreted. Initially, its amount decreases to 400 ml daily (this condition is called oliguria ), later the patient excretes no more than 50 ml of urine per day (determined anuria ). The patient complains of nausea, he also vomits, and his appetite disappears.
The person becomes lethargic, drowsy, has a mental retardation, and sometimes has convulsions and hallucinations.
The condition of the skin also changes. It becomes very dry, pale, swelling and hemorrhages may appear. The person breathes frequently and deeply, and has tachycardia . the heart rhythm is disrupted and blood pressure rises. May also be noted loose stool And bloating .
Anuria is cured if treatment for anuria was started in a timely manner and carried out correctly. To do this, the doctor must clearly determine the causes of anuria. If therapy is carried out correctly, the symptoms of anuria gradually disappear and a period begins when diuresis is restored. During the period of improvement of the patient's condition, anuria is characterized by a daily diuresis of 3-5 liters. However, in order for health to be fully restored, it takes from 6 to 18 months.
Thus, the course of the disease is divided into four stages. At the initial stage, a person’s condition directly depends on the cause that provoked renal failure. In the second, oligoanuric stage, the amount of urine decreases sharply, or it may be completely absent. This stage is the most dangerous, and if it continues for too long, coma and even death. In the third, diuretic stage, the patient gradually increases the amount of urine that is released. Next comes the fourth stage - recovery.
Diagnostics
A patient with suspected renal failure or with signs of anuria is prescribed a series of examinations. First of all, this is a consultation with a urologist, biochemical and clinical blood tests, ultrasound, intravenous urography. Anuria is easy to diagnose, since by interviewing the patient it can be understood that he has not had urination or the urge to urinate for a long time. To differentiate this condition from acute urinary retention, catheterization of the bladder is performed to confirm the absence of urine in it.
Treatment
All patients who present with symptoms of acute renal failure should be urgently transported to hospital, where diagnosis and subsequent treatment are carried out in the intensive care unit or in the nephrology department. The leading importance in this case is to begin treatment of the underlying disease as early as possible in order to eliminate all the causes that led to kidney damage. Considering the fact that the pathogenesis of the disease is most often determined by the effect of shock on the body, it is necessary to promptly carry out anti-shock measures . The classification of disease types is of decisive importance in the choice of treatment methods. Thus, in case of renal failure caused by blood loss, it is compensated by administering blood substitutes. If poisoning initially occurs, gastric lavage is required to remove toxic substances. In case of severe renal failure, hemodialysis or peritoneal dialysis is necessary.
Especially serious condition causes end-stage chronic renal failure. In this case, kidney function is completely lost, and toxins accumulate in the body. As a result, this condition leads to serious complications. Therefore, chronic renal failure in children and adults must be properly treated.
Treatment of renal failure is carried out gradually, taking into account certain stages. Initially, the doctor determines the reasons that led to the patient developing signs of renal failure. Next, it is necessary to take measures in order to achieve a relatively normal volume of urine that is excreted in a person.
Depending on the stage of renal failure, conservative treatment is carried out. Its goal is to reduce the amount of nitrogen, water and electrolytes that enter the body so that this amount matches that which is excreted from the body. In addition, an important point in the recovery of the body is diet in case of renal failure, constant monitoring of its condition, as well as monitoring biochemical parameters. Particular care should be taken in treatment if there is renal failure in children.
The next important step in the treatment of anuria is to carry out dialysis therapy . In some cases, dialysis therapy is used to prevent complications already in the early stages diseases.
The absolute indication for a patient to undergo dialysis is symptomatic uremia, the accumulation of fluid in the patient’s body that cannot be eliminated using conservative methods.
Particular importance is given to the nutrition of patients. The fact is that both hunger and thirst can dramatically worsen a person’s condition. In this case it is shown low protein diet . that is, fats and carbohydrates should dominate the diet. If a person cannot feed himself, glucose and nutritional mixtures must be administered intravenously.
Complications
The course of acute renal failure is often complicated by infectious diseases. It is with this course that the disease can be fatal.
Complications from the cardiovascular system include: circulatory failure . arrhythmias . hypertension . pericarditis . Often in acute renal failure there is a manifestation of neurological disorders. Those patients who are not on dialysis may note severe drowsiness . disturbances of consciousness, tremors and other disorders of the nervous system. More often, such disorders develop in older people.
From the outside Gastrointestinal tract Complications also develop frequently. This may be nausea, anorexia, or intestinal obstruction.
Prevention
To prevent the development of such dangerous condition the body, first of all, it is necessary to provide timely qualified assistance those patients who have a high risk of developing acute renal failure. These are people with severe injuries, burns; those who have just suffered major surgery, patients with sepsis, eclampsia, etc. You should use very carefully those medications that are nephrotoxic .
In order to prevent the development of chronic renal failure, which develops as a consequence of a number of kidney diseases, it is necessary to prevent exacerbation of pyelonephritis and glomerulonephritis. It is important for chronic forms of these diseases to follow a strict diet prescribed by a doctor. Patients with chronic kidney disease should see their doctor regularly.
Stage 5 Chronic Kidney Failure (CRF)
* Belching
* Shortness of breath caused by fluid accumulation
* Muscle cramp
* Tingling hands and feet
*Difficulty concentrating
*Decreased urine output
* Feeling tired and getting weaker and weaker
* Change in urine color
* Increased skin pigmentation
Kidneys are very important for our health. In the stage of kidney failure, the kidneys are unable to effectively excrete toxins and additional water from the body, and they cannot yet do things like regulate blood pressure, maintain the balance of electrolytes like potassium, phosphorus, etc. and produce erythropoietin to stimulate blood cell production.
Patients with stage 5 renal failure require a nephrologist. Patients will suffer from urine test and blood test for creatinine and electrolyte, and the doctor will advise treatment recommendations to reduce the complexion and make patients feel healthier. The doctor will probably recommend dialysis or some of their doctors will prepare a kidney transplant. There are two types of dialysis: peritoneal dialysis and hemodialysis. Before dialysis, patients will have questions. The essence of dialysis is only a method that helps patients live a long time, but it cannot improve the kidneys and cause side effects. When dialysis is necessary for patients, the doctor will simply advise taking this treatment and choosing which type to treat. As for kidney transplantation, patients will evaluate whether transplantation is possible, the risk of recurrence, and which kidney would be suitable.
If a person finds natural treatments, then Chinese medicine treatment will be your choice. Treatment with Chinese medicines, despite its slow effects, comparable with Western medicine, will be able to nourish the kidneys, refrain from inflammation, accelerate the addition of nutrient to repair damaged (not completely damaged) kidney cells, and accompanying kidney correction, clinical symptoms/complications will be better controlled, and patients can feel much relieved.
Diet is so important in reducing the risk of complications and improving overall health that patients should visit a dietician. And the dietician will provide a diet plan that is based on personal laboratory result and the underlying situation of the disease. Dietary tips for stage 5 kidney failure include:
More vegetables, grains and fruits may be included, but be careful to limit or avoid foods high in potassium and phosphorus. Limit your total fat intake, and replace saturated fats with unsaturated fats. And this helps prevent cardiovascular diseases.
Limit your intake of refined and processed foods high in sodium, and prepare a low-sodium lunch.
Sufficient protein supplementation to supplement protein loss due to dialysis.
Goal for a healthy body weight by calorie intake based on body size and individual needs.
If the urine output is less than 1 liter per day (almost 32 ounces) and? Serum potassium above 5.0, low potassium diet is recommended.
Avoid foods high in potassium and monitor your potassium levels by getting regular blood tests.
Limit 2000 mg calcium and 1000 mg phosphorus based on individual requirements.
Remember that there really is no diet that fits every kidney disease condition. Patients need to make a diet plan based on individual condition after talking with a doctor. Please note that this may be a kidney complication that can be dangerous. Check your illness as often as possible and communicate with your doctor regularly to know if treatment or dietary changes are needed.
If you have any questions, please contact us via phone +86-311-89261580 or email [email protected] or skype:hospital.kidney. We will answer your questions as soon as possible.
Treatment of chronic renal failure
Chronic renal failure- a symptom complex caused by a sharp decrease in the number and function of nephrons, which leads to disruption of the excretory and incretory functions of the kidneys, homeostasis, disorders of all types of metabolism, blood sugar, and the activity of all organs and systems.
For the correct selection of adequate treatment methods, it is extremely important to take into account the classification of chronic renal failure.
1. Conservative stage with a drop in glomerular filtration to 40-15 ml/min with great possibilities for conservative treatment.
2. Terminal stage with glomerular filtration rate of about 15 ml/min, when the issue of extrarenal cleansing (hemodialysis, peritoneal dialysis) or kidney transplantation should be discussed.
1. Treatment of chronic renal failure in the conservative stage
Treatment program for chronic renal failure in the conservative stage.
1. Treatment of the underlying disease that led to uremia.
2. Mode.
3. Medical nutrition.
4. Adequate fluid intake (correction of water balance disorders).
5. Correction of electrolyte metabolism disorders.
6. Reducing the retention of end products of protein metabolism (combat azotemia).
7. Correction of acidosis.
8. Treatment of arterial hypertension.
9. Treatment of anemia.
10. Treatment of uremic osteodystrophy.
11. Treatment infectious complications.
1.1. Treatment of the underlying disease
Treatment of the underlying disease that led to the development of chronic renal failure at a conservative stage may still have a beneficial effect positive influence and even reduce the severity of chronic renal failure. This especially applies to chronic pyelonephritis with initial or moderate symptoms of chronic renal failure. Stopping the exacerbation of the inflammatory process in the kidneys reduces the severity of renal failure.
1.2. Mode
The patient should avoid hypothermia, heavy physical and emotional stress. The patient needs optimal working and living conditions. He must be surrounded by attention and care, he must be provided extra rest during work, a longer vacation is also advisable.
1.3. Medical nutrition
The diet for chronic renal failure is based on the following principles:
- limiting dietary protein intake to 60-40-20 g per day, depending on the severity of renal failure;
- ensuring sufficient calorie content of the diet corresponding to the energy needs of the body, due to fats, carbohydrates, complete provision of the body with microelements and vitamins;
- limiting the intake of phosphates from food;
- control over the intake of sodium chloride, water and potassium.
The implementation of these principles, especially the restriction of protein and phosphates in the diet, reduces the additional load on functioning nephrons and contributes to more long-term preservation satisfactory renal function, reduction of azotemia, slow down the progression of chronic renal failure. Limiting protein in food reduces the formation and retention of nitrogenous waste in the body, reduces the content of nitrogenous waste in the blood serum due to a decrease in the formation of urea (with the breakdown of 100 g of protein, 30 g of urea is formed) and due to its reutilization.
In the early stages of chronic renal failure, when the level of creatinine in the blood is up to 0.35 mmol/l and urea up to 16.7 mmol/l (glomerular filtration about 40 ml/min), moderate protein restriction to 0.8-1 g/kg is recommended, i.e. up to 50-60 g per day. At the same time, 40 g should be high-value protein in the form of meat, poultry, eggs, and milk. It is not recommended to overuse milk and fish due to their high phosphate content.
When serum creatinine levels are from 0.35 to 0.53 mmol/l and urea levels are 16.7-20.0 mmol/l (glomerular filtration rate is about 20-30 ml/min), protein should be limited to 40 g per day (0.5-0.6 g/kg). At the same time, 30 g should be high-value protein, and bread, cereals, potatoes and other vegetables should account for only 10 g of protein per day. 30-40 g of complete protein per day is the minimum amount of protein required to maintain a positive nitrogen balance. If a patient with chronic renal failure has significant proteinuria The protein content in food is increased according to the loss of protein in the urine, adding one egg (5-6 g of protein) for every 6 g of urine protein. In general, the patient’s menu is compiled within table No. 7. The patient’s daily diet includes following products: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, pearl barley porridge. Particularly suitable due to their low protein content and at the same time high energy value are potato dishes (pancakes, cutlets, babkas, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar per glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and, in doses, proteins. Calculating the daily amount of protein in the diet is mandatory. When compiling a menu, you should use tables reflecting the protein content of the product and its energy value ( table 1 ).
Table 1. Protein content and energy value
some food products (per 100 g of product)
| Product | Protein, g | Energy value, kcal |
| Meat (all types) Milk Kefir Cottage cheese Cheese (cheddar) Sour cream Cream (35%) Egg (2 pcs.) Fish Potato Cabbage cucumbers Tomatoes Carrot Eggplant Pears Apples Cherry Oranges Apricots Cranberry Raspberries Strawberry Honey or jam Sugar Wine Butter Vegetable oil Potato starch Rice (boiled) Pasta Oatmeal Noodles | 23.0 | 250 |
Table 2. Approximate daily set of foods (diet No. 7)
per 50 g of protein for chronic renal failure
| Product | Net weight, g | Proteins, g | Fats, g | Carbohydrates, g |
| Milk | 400 | 11.2 | 12.6 | 18.8 |
| It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g |
||||
An approximate version of diet No. 7 for 40 g of protein per day:
Wide use received potato and potato-egg diets in the treatment of patients with chronic renal failure. These diets are high in calories due to protein-free foods - carbohydrates and fats. High calorie food reduces catabolism and reduces the breakdown of your own protein. Honey, sweet fruits (poor in protein and potassium), can also be recommended as high-calorie foods. vegetable oil, lard (in the absence of edema and hypertension). There is no need to prohibit alcohol in chronic renal failure (with the exception of alcoholic nephritis, where abstinence from alcohol can lead to improved kidney function).
1.4. Correction of water balance disorders
If the level of creatinine in the blood plasma is 0.35-1.3 mmol/l, which corresponds to a glomerular filtration rate of 10-40 ml/min, and there are no signs of heart failure, then the patient should take enough fluid to maintain diuresis within 2-2.5 l per day. day. In practice, we can assume that under the above conditions there is no need to limit fluid intake. This water regime makes it possible to prevent dehydration and at the same time release an adequate amount of fluid due to osmotic diuresis in the remaining nephrons. In addition, high diuresis reduces the reabsorption of waste in the tubules, promoting their maximum excretion. Increased fluid flow in the glomeruli increases glomerular filtration. When the glomerular filtration rate is more than 15 ml/min, the risk of fluid overload during oral administration is minimal.
In some cases, with the compensated stage of chronic renal failure, symptoms of dehydration may appear due to compensatory polyuria, as well as vomiting and diarrhea. Dehydration can be cellular (excruciating thirst, weakness, drowsiness, reduced skin turgor, sunken face, very dry tongue, increased blood viscosity and hematocrit, possibly increased body temperature) and extracellular (thirst, asthenia, dry sagging skin, sunken face, arterial hypotension , tachycardia). With the development of cellular dehydration, intravenous administration of 3-5 ml of 5% glucose solution per day under the control of central venous pressure is recommended. For extracellular dehydration, an isotonic sodium chloride solution is administered intravenously.
1.5. Correction of electrolyte imbalances
The intake of table salt in patients with chronic renal failure without edema syndrome and arterial hypertension should not be limited. Sharp and prolonged salt restriction leads to dehydration of patients, hypovolemia and deterioration of kidney function, increasing weakness, and loss of appetite. The recommended amount of salt in the conservative phase of chronic renal failure in the absence of edema and arterial hypertension is 10-15 g per day. With the development of edema syndrome and severe arterial hypertension, the consumption of table salt should be limited. Patients with chronic glomerulonephritis with chronic renal failure are allowed 3-5 g of salt per day, with chronic pyelonephritis with chronic renal failure - 5-10 g per day (in the presence of polyuria and the so-called salt-losing kidney). It is advisable to determine the amount of sodium excreted in the urine per day in order to calculate the required amount of table salt in the diet.
In the polyuric phase of chronic renal failure, pronounced losses of sodium and potassium in the urine may occur, which leads to the development hyponatremia And hypokalemia.
In order to accurately calculate the amount of sodium chloride (in g) a patient needs per day, you can use the formula: amount of sodium excreted in urine per day (in g) X 2.54. Practically, 5-6 g of table salt per 1 liter of urine excreted is added to the patient’s food. The amount of potassium chloride needed per day by a patient to prevent the development of hypokalemia in the polyuric phase of chronic renal failure can be calculated using the formula: amount of potassium excreted in urine per day (in g) X 1.91. When hypokalemia develops, the patient is given vegetables and fruits rich in potassium (Table 43), as well as potassium chloride orally in the form of a 10% solution, based on the fact that 1 g of potassium chloride (i.e. 10 ml of a 10% solution of potassium chloride) contains 13.4 mmol potassium or 524 mg potassium (1 mmol potassium = 39.1 mg).
With moderate hyperkalemia(6-6.5 mmol/l) foods rich in potassium should be limited in the diet, potassium-sparing diuretics should be avoided, and ion exchange resins should be taken ( resonium 10 g 3 times a day per 100 ml of water).
For hyperkalemia of 6.5-7 mmol/l, it is advisable to add intravenous glucose with insulin (8 units of insulin per 500 ml of 5% glucose solution).
With hyperkalemia above 7 mmol/l there is a risk of cardiac complications (extrasystole, atrioventricular block, asystole). In this case, in addition to intravenous administration of glucose with insulin, intravenous administration of 20-30 ml of 10% calcium gluconate solution or 200 ml of 5% sodium bicarbonate solution is indicated.
For measures to normalize calcium metabolism, see the section “Treatment of uremic osteodystrophy.”
Table 3. Potassium content in 100 g of products
1.6. Reducing the retention of end products of protein metabolism (combat azotemia)
1.6.1. Diet
For chronic renal failure, a diet with reduced content squirrel (see above).
7.6.2. Sorbents
Sorbents used along with the diet adsorb ammonia and other toxic substances in the intestines.
Most often used as sorbents enterodesis or carbolene 5 g per 100 ml of water 3 times a day 2 hours after meals. Enterodes is a low molecular weight polyvinylpyrrolidone preparation that has detoxification properties, binds toxins entering the gastrointestinal tract or formed in the body, and removes them through the intestines. Sometimes oxidized starch in combination with coal is used as sorbents.
Widely used in chronic renal failure enterosorbents- different kinds activated carbon for oral administration. You can use enterosorbents of the IGI, SKNP-1, SKNP-2 brands at a dose of 6 g per day. Enterosorbent is produced in the Republic of Belarus Belosorb-II, which is used 1-2 g 3 times a day. The addition of sorbents increases the excretion of nitrogen in feces and leads to a decrease in the concentration of urea in the blood serum.
1.6.3. Colon lavage, intestinal dialysis
With uremia, up to 70 g of urea, 2.9 g of creatinine, 2 g of phosphates and 2.5 g of uric acid are released into the intestines per day. By removing these substances from the intestines, intoxication can be reduced, so intestinal lavage, intestinal dialysis, and siphon enemas are used to treat chronic renal failure. Intestinal dialysis is the most effective. It is performed using a two-channel probe up to 2 m long. One channel of the probe is designed to inflate a balloon, with which the probe is fixed in the intestinal lumen. The probe is inserted under control x-ray examination into the jejunum, where it is fixed with a balloon. Through another channel, the probe is inserted into the small intestine over 2 hours in equal portions of 8-10 liters. hypertonic solution the following composition: sucrose - 90 g/l, glucose - 8 g/l, potassium chloride - 0.2 g/l, sodium bicarbonate - 1 g/l, sodium chloride - 1 g/l. Intestinal dialysis is effective for moderate symptoms of uremic intoxication.
In order to develop a laxative effect and thereby reduce intoxication, they are used sorbitol And xylitol. When administered orally in a dose of 50 g, severe diarrhea develops with loss of significant amount liquids (3-5 liters per day) and nitrogenous wastes.
If hemodialysis is not possible, the method of controlled forced diarrhea using hyperosmolar Young's solution the following composition: mannitol - 32.8 g/l, sodium chloride - 2.4 g/l, potassium chloride - 0.3 g/l, calcium chloride - 0.11 g/l, sodium bicarbonate - 1.7 g/l. Within 3 hours you should drink 7 liters of warm solution (1 glass every 5 minutes). Diarrhea begins 45 minutes after starting to take Young's solution and ends 25 minutes after stopping taking it. The solution is taken 2-3 times a week. It tastes good. Mannitol can be replaced with sorbitol. After each procedure, urea in the blood decreases by 37.6%. potassium - by 0.7 mmol/l, the level of bicarbonates increases, krsatinina - does not change. The duration of treatment is from 1.5 to 16 months.
1.6.4. Gastric lavage (dialysis)
It is known that with a decrease in the nitrogen excretory function of the kidneys, urea and other products of nitrogen metabolism begin to be released by the gastric mucosa. In this regard, gastric lavage can reduce azotemia. Before gastric lavage, the level of urea in the gastric contents is determined. If the level of urea in the gastric contents is 10 mmol/l or more less than the level in the blood, the excretory capabilities of the stomach are not exhausted. 1 liter of 2% sodium bicarbonate solution is injected into the stomach, then sucked off. Washing is done in the morning and evening. In 1 session you can remove 3-4 g of urea.
1.6.5. Antiazotemic agents
Antiazotemic agents have the ability to increase the secretion of urea. Despite the fact that many authors consider their anti-azotemic effect to be problematic or very weak, these drugs have gained great popularity among patients with chronic renal failure. In the absence of individual intolerance, they can be prescribed in the conservative stage of chronic renal failure.
Hofitol- purified extract of the cinara scolymus plant, available in ampoules of 5-10 ml (0.1 g of pure substance) for intravenous and intramuscular injection, course of treatment - 12 injections.
Lespenefril- obtained from the stems and leaves of the legume plant Lespedeza capitate, available in the form alcohol tincture or lyophilized extract for injection. It is used orally at 1-2 teaspoons per day, in more severe cases - starting from 2-3 to 6 teaspoons per day. For maintenance therapy, it is prescribed for a long time - 1 teaspoon every other day. Lespenefril is also available in ampoules in the form of lyophilized powder. Administered intravenously or intramuscularly (an average of 4 ampoules per day). It is also administered intravenously in an isotonic sodium chloride solution.
1.6.6. Anabolic drugs
Anabolic drugs are used to reduce azotemia in the initial stages of chronic renal failure; when treated with these drugs, urea nitrogen is used for protein synthesis. Recommended retabolil 1 ml intramuscularly 1 time per week for 2-3 weeks.
1.6.7. Parenteral administration of detoxification agents
Hemodez, 5% glucose solution, etc. are used.
1.7. Correction of acidosis
Acidosis usually does not produce clear clinical manifestations. The need for its correction is due to the fact that with acidosis, bone changes may develop due to constant delay hydrogen ions; in addition, acidosis contributes to the development of hyperkalemia.
In moderate acidosis, protein restriction in the diet leads to an increase in pH. In mild cases, to relieve acidosis, you can use soda (sodium bicarbonate) orally in a daily dose of 3-9 g or sodium lactate 3-6 g per day. Sodium lactate is contraindicated in cases of liver dysfunction, heart failure and other conditions accompanied by the formation of lactic acid. In mild cases of acidosis, you can also use sodium citrate orally in a daily dose of 4-8 g. In case of severe acidosis, sodium bicarbonate is administered intravenously in the form of a 4.2% solution. The amount of 4.2% solution required to correct acidosis can be calculated as follows: 0.6 x BE x body weight (kg), where BE is the deficiency of buffer bases (mmol/l). If it is not possible to determine the shift of buffer bases and calculate their deficiency, you can administer a 4.2% soda solution in an amount of about 4 ml/kg. I. E. Tareeva draws attention to the fact that intravenous administration of a soda solution in an amount of more than 150 ml requires special caution due to the risk of depression of cardiac activity and the development of heart failure.
When using sodium bicarbonate, acidosis is reduced and, as a result, the amount of ionized calcium also decreases, which can lead to seizures. In this regard, intravenous administration of 10 ml of 10% calcium gluconate solution is advisable.
Often used in the treatment of severe acidosis. trisamine. Its advantage is that it penetrates the cell and corrects intracellular pH. However, many consider the use of trisamine contraindicated in cases of impaired renal excretory function; in these cases, severe hyperkalemia is possible. Therefore, trisamine has not received widespread use as a means to relieve acidosis in chronic renal failure.
Relative contraindications to alkali infusions are: edema, heart failure, high arterial hypertension, hypernatremia. For hypernatremia, the combined use of soda and 5% glucose solution in a ratio of 1:3 or 1:2 is recommended.
1.8. Treatment of arterial hypertension
It is necessary to strive to optimize blood pressure, since hypertension sharply worsens the prognosis and reduces the life expectancy of patients with chronic renal failure. Blood pressure should be kept within 130-150/80-90 mmHg. Art. In most patients with a conservative stage of chronic renal failure, arterial hypertension is moderately expressed, i.e. systolic blood pressure ranges from 140 to 170 mm Hg. Art., and diastolic - from 90 to 100-115 mm Hg. Art. Malignant arterial hypertension in chronic renal failure is observed infrequently. The reduction in blood pressure should be carried out under the control of diuresis and glomerular filtration. If these indicators decrease significantly with a decrease in blood pressure, the dose of drugs should be reduced.
Treatment of patients with chronic renal failure with arterial hypertension includes:
Restriction in the diet of table salt to 3-5 g per day, with severe arterial hypertension - to 1-2 g per day, and as soon as blood pressure normalizes, salt consumption should be increased.
Prescription of natriuretics - furosemide at a dose of 80-140-160 mg per day, uregita(ethacrynic acid) up to 100 mg per day. Both drugs slightly increase glomerular filtration. These drugs are used in tablets, and for pulmonary edema and other urgent conditions - intravenously. In large doses, these drugs can cause hearing loss and increase the toxic effect of cephalosporins. If the antihypertensive effect of these diuretics is insufficient, any of them can be combined with hypothiazide (25-50 mg orally in the morning). However, hypothiazide should be used at creatinine levels up to 0.25 mmol/l; at higher creatinine levels, hypothiazide is ineffective, and the risk of hyperuricemia increases.
Prescribing antihypertensive drugs with predominantly central adrenergic action - dopegite And clonidine. Dopegite is converted into alphamethylnorepinephrine in the central nervous system and causes a decrease in blood pressure by enhancing the depressant effects of the paraventricular nucleus of the hypothalamus and stimulating the postsynaptic α-adrenergic receptors of the medulla oblongata, which leads to a decrease in the tone of the vasomotor centers. Dopegit can be used in a dose of 0.25 g 3-4 times a day, the drug increases glomerular filtration, however, its elimination in chronic renal failure is significantly slowed down and its metabolites can accumulate in the body, causing a number of side effects, in particular, depression of the central nervous system and a decrease in myocardial contractility, therefore, the daily dose should not exceed 1.5 g. Clonidine stimulates α-adrenergic receptors of the central nervous system, which leads to inhibition of sympathetic impulses from the vasomotor center to the medullary substance and medulla oblongata, which causes a decrease in blood pressure. The drug also reduces the content of renin in the blood plasma. Clonidine is prescribed at a dose of 0.075 g 3 times a day; if the hypotensive effect is insufficient, the dose is increased to 0.15 mg 3 times a day. It is advisable to combine dopegit or clonidine with saluretics - furosemide, hypothiazide, which allows you to reduce the dose of clonidine or dopegit and reduce the side effects of these drugs.
In some cases, it is possible to use beta-blockers ( anaprilina, obsidan, inderala). These drugs reduce the secretion of renin, their pharmacokinetics in chronic renal failure are not affected, therefore I. E. Tareeva allows their use in large daily doses - up to 360-480 mg. However, such large doses are not always required. It is better to take smaller doses (120-240 mg per day) to avoid side effects. Therapeutic effect drugs are enhanced when combined with saluretics. When arterial hypertension is combined with heart failure during treatment with beta-blockers, caution should be exercised.
In the absence of a hypotensive effect from the above measures, it is advisable to use peripheral vasodilators, since these drugs have a pronounced hypotensive effect and increase renal blood flow and glomerular filtration. Applicable prazosin(minipress) 0.5 mg 2-3 times a day. ACE inhibitors are especially indicated - hood(captopril) 0.25-0.5 mg/kg 2 times a day. The advantage of capoten and its analogues is their normalizing effect on intraglomerular hemodynamics.
For arterial hypertension refractory to treatment, ACE inhibitors are prescribed in combination with saluretics and beta blockers. Doses of drugs are reduced as chronic renal failure progresses, the glomerular filtration rate and the level of azotemia are constantly monitored (if the renovascular mechanism of arterial hypertension predominates, filtration pressure and glomerular filtration rate decrease).
For cupping hypertensive crisis for chronic renal failure, furosemide or verapamil is administered intravenously, captopril, nifedipine or clonidine are used sublingually. If there is no effect from drug therapy, extracorporeal methods for removing excess sodium are used: isolated blood ultrafiltration, hemodialysis (I. M. Kutyrina, N. L. Livshits, 1995).
Often, a greater effect of antihypertensive therapy can be achieved not by increasing the dose of one drug, but by a combination of two or three drugs acting on various pathogenetic links of hypertension, for example, a saluretic and a sympatholytic, a beta blocker and a saluretic, a centrally acting drug and a saluretic, etc.
1.9. Treatment of anemia
Unfortunately, treatment of anemia in patients with chronic renal failure is not always effective. It should be noted that most patients with chronic renal failure tolerate anemia satisfactorily with a decrease in hemoglobin levels even to 50-60 g/l, as adaptive reactions develop that improve the oxygen transport function of the blood. The main directions of treatment of anemia in chronic renal failure are as follows.
1.9.1. Treatment with iron supplements
Iron preparations are usually taken orally and only in case of poor tolerance and gastrointestinal disorders they are administered intravenously or intramuscularly. Most often prescribed ferroplex 2 tablets 3 times a day after meals; ferrocerone conference 2 tablets 3 times a day; ferrograduate, tardiferon(extended-release iron preparations) 1-2 tablets 1-2 times a day ( table 4
).
Table 4. Oral preparations containing ferrous iron
Iron supplements should be dosed based on the fact that the minimum effective daily dose of ferrous iron for an adult is 100 mg, and the maximum appropriate daily dose is 300-400 mg. Therefore, it is necessary to begin treatment with minimal doses, then gradually, if the drugs are well tolerated, the dose is increased to the maximum appropriate. The daily dose is taken in 3-4 doses, and extended-release drugs are taken 1-2 times a day. Iron supplements are taken 1 hour before meals or no earlier than 2 hours after meals. Total duration of treatment oral medications is at least 2-3 months, and often up to 4-6 months, which is required to fill the depot. After reaching a hemoglobin level of 120 g/l, taking the drugs continues for at least 1.5-2 months, in the future it is possible to switch to maintenance doses. However, it is, of course, usually not possible to normalize hemoglobin levels due to the irreversibility of the pathological process underlying chronic renal failure.
1.9.2. Androgen treatment
Androgens activate erythropoiesis. They are prescribed to men in relatively large doses - testosterone intramuscularly 400-600 mg of 5% solution once a week; Sustanon, testenate intramuscularly 100-150 mg of 10% solution 3 times a week.
1.9.3. Treatment with Recormon
Recombinant erythropoietin - Recormon is used to treat erythropoietin deficiency in patients with chronic renal failure. One ampoule of the drug for injection contains 1000 IU. The drug is administered only subcutaneously, the initial dose is 20 IU/kg 3 times a week, then, if there is no effect, the number of injections is increased by 3 every month. The maximum dose is 720 units/kg per week. After an increase in hematocrit by 30-35%, a maintenance dose is prescribed, which is equal to half the dose at which the hematocrit increased, the drug is administered at 1-2 week intervals.
Side effects of Recormon: increased blood pressure (in case of severe arterial hypertension, the drug is not used), increased platelet count, the appearance of a flu-like syndrome at the beginning of treatment (headache, joint pain, dizziness, weakness).
Treatment with erythropoietin is currently the most effective method of treating anemia in patients with chronic renal failure. It has also been established that treatment with erythropoietin has a positive effect on the function of many endocrine organs(F. Kokot, 1991): renin activity is suppressed, the level of aldosterone in the blood decreases, the content of atrial natriuretic factor in the blood increases, the levels of growth hormone, cortisol, prolactin, ACTH, pancreatic polypeptide, glucagon, gastrin also decrease, the secretion of testosterone increases, which along with with a decrease in prolactin, it has a positive effect on the sexual function of men.
1.9.4. Red blood cell transfusion
Transfusion of red blood cells is performed in cases of severe anemia (hemoglobin level below 50-45 g/l).
1.9.5. Multivitamin therapy
It is advisable to use balanced multivitamin complexes(undevite, oligovite, duoovite, decamevite, fortevit, etc.).
1.10. Treatment of uremic osteodystrophy
1.10.1. Keeping close to normal level calcium and phosphorus in the blood
Typically, calcium levels in the blood are low and phosphorus levels are high. The patient is prescribed calcium supplements in the form of the most easily absorbed calcium carbonate in a daily dose of 3 g with a glomerular filtration rate of 10-20 ml/min and about 5 g per day with a glomerular filtration rate of less than 10 ml/min.
It is also necessary to reduce the intake of phosphates from food (they are found mainly in protein-rich foods) and prescribe drugs that reduce the absorption of phosphates in the intestines. It is recommended to take Almagel 10 ml 4 times a day; it contains aluminum hydroxide, which forms insoluble compounds with phosphorus that are not absorbed in the intestines.
1.10.2. Suppressing overactive parathyroid glands
This principle of treatment is carried out by taking calcium orally (based on the feedback principle, this inhibits the function of the parathyroid glands), as well as taking medications vitamin D- oil or alcohol solution of vitamin D (ergocalciferol) in a daily dose of 100,000 to 300,000 IU; more efficient vitamin D 3(Oxidevit), which is prescribed in capsules at 0.5-1 mcg per day.
Vitamin D preparations significantly enhance the absorption of calcium in the intestine and increase its level in the blood, which inhibits the function of the parathyroid glands.
Close to vitamin D, but has a more energetic effect tahistin- 10-20 drops of 0.1% oil solution 3 times a day orally.
As the level of calcium in the blood increases, the dosage of the drugs is gradually reduced.
For advanced uremic osteodystrophy, subtotal parathyroidectomy may be recommended.
1.10.3. Treatment with osteoquin
In recent years, a drug has appeared osteoquin(ipriflavone) for the treatment of osteoporosis of any origin. The proposed mechanism of its action is inhibition of bone resorption by enhancing the action of endogenous calcitonin and improving mineralization due to calcium retention. The drug is prescribed at a dose of 0.2 g 3 times a day for an average of 8-9 months.
1.11. Treatment of infectious complications
The appearance of infectious complications in patients with chronic renal failure leads to a sharp decrease in renal function. If there is a sudden drop in glomerular filtration rate in a nephrology patient, the possibility of infection must first be excluded. When carrying out antibacterial therapy, one should remember the need to reduce doses of drugs, taking into account the impairment of renal excretory function, as well as the nephrotoxicity of a number of antibacterial agents. The most nephrotoxic antibiotics are aminoglycosides (gentamicin, kanamycin, streptomycin, tobramycin, brulamycin). The combination of these antibiotics with diuretics increases the possibility of toxic effects. Tetracyclines are moderately nephrotoxic.
The following antibiotics are not nephrotoxic: chloramphenicol, macrolides (erythromycin, oleandomycin), oxacillin, methicillin, penicillin and other drugs of the penicillin group. These antibiotics may be prescribed usual doses. For urinary tract infections, preference is also given to cephalosporins and penicillins secreted by tubules, which ensures their sufficient concentration even with a decrease in glomerular filtration ( table 5 ).
Nitrofuran compounds and nalidixic acid preparations can be prescribed for chronic renal failure only in the latent and compensated stages.
Table 5. Doses of antibiotics for various degrees renal failure
| A drug | One-time | Intervals between injections |
|||
| more than 70 | 20-30 | 20-10 | less than 10 |
||
| Gentamicin | 0.04 | 8 | 12 | 24 | 24-48 |
Note: in case of significant impairment of renal function, the use of aminoglycosides (gentamicin, kanamycin, streptomycin) is not recommended.
2. Basic principles of treatment of end-stage chronic renal failure
2.1. Mode
The regimen for patients with end-stage chronic renal failure should be as gentle as possible.
2.2. Medical nutrition
In the terminal stage of chronic renal failure with a glomerular filtration rate of 10 ml/min and below and with a urea level in the blood of more than 16.7 mmol/l with severe symptoms of intoxication, diet No. 7 is prescribed with protein limitation to 0.25-0.3 g/kg, a total of 20-25 g of protein per day, and 15 g of protein should be complete. It is also advisable to take essential amino acids (especially histidine, tyrosine), their keto analogues, and vitamins.
The principle of the therapeutic effect of a low-protein diet lies primarily in the fact that in case of uremia, low amino acid content in plasma and low protein intake from food, urea nitrogen is used in the body for the synthesis of essential amino acids and protein. A diet containing 20-25 g of protein is prescribed to patients with chronic renal failure only for a limited time - for 20-25 days.
As the concentration of urea and creatinine in the blood decreases, intoxication and dyspeptic symptoms decrease in patients, the feeling of hunger increases, and they begin to lose body weight. During this period, patients are transferred to a diet containing 40 g of protein per day.
Options for a low-protein diet according to A. Dolgodvorov(proteins 20-25 g, carbohydrates - 300-350 g, fats - 110 g, calories - 2500 kcal):
Separately, patients are given histidine at a dose of 2.4 g per day.
Options for a low-protein diet according to S. I. Ryabov(proteins - 18-24 g, fats - 110 g, carbohydrates - 340-360 g, sodium - 20 mmol, potassium - 50 mmol, calcium 420 mg, phosphorus - 450 mg).
With each option, the patient receives 30 g of butter, 100 g of sugar, 1 egg, 50-100 g of jam or honey, 200 g of protein-free bread per day. Sources of amino acids in the diet are eggs, fresh vegetables, fruits, in addition, 1 g of methionine is given per day. Adding spices is allowed: bay leaf, cinnamon, cloves. You can drink a small amount of dry grape wine. Meat and fish are prohibited.
| 1st option | 2nd option |
| First breakfast Lunch Dinner Dinner | First breakfast Lunch Dinner Dinner |
N.A. Ratner suggests using potato diet as a low-protein diet. At the same time, high calorie content is achieved through protein-free foods - carbohydrates and fats ( table 6 ).
Table 6. Low-protein potato diet (N. A. Ratner)
| - - |
||||||||
| Total | ||||||||
The diet is well tolerated by patients, but is contraindicated if there is a tendency to hyperkalemia.
S.I. Ryabov developed variants of diet No. 7 for patients with chronic renal failure who are on hemodialysis. This diet has been expanded due to the loss of amino acids during hemodialysis, so S.I. Ryabov suggests including a small amount of meat and fish in the diet (up to 60-70 g of protein per day during hemodialysis).
| 1st option | 2nd option | 3rd option |
| Breakfast
Dinner | Breakfast
| Breakfast Dinner
|
A promising addition to a low-protein diet is the use of sorbents, as in the conservative stage of chronic renal failure: oxycellulose in an initial dose of 40 g, followed by increasing the dose to 100 g per day; starch 35 g daily for 3 weeks; polyaldehyde "polyacromene" 40-60 g per day; carbolene 30 g per day; enterodesis; coal enterosorbents.
Completely protein-free diets are also offered (for 4-6 weeks) with the introduction of only essential acids or their keto analogues (ketosteril, ketoperlene) from nitrogenous substances. When using such diets, the content of urea first decreases, and then uric acid, methylguanidine and, to a lesser extent, creatinine, and the level of hemoglobin in the blood may increase.
The difficulty of following a low-protein diet lies primarily in the need to exclude or sharply limit foods containing vegetable protein: bread, potatoes, cereals. Therefore, you should take low-protein bread made from wheat or corn starch (100 g of such bread contains 0.78 g of protein) and artificial sago (0.68 g of protein per 100 g of product). Sago is used instead of various grains.
2.3. Controlling fluid administration
In the terminal stage of chronic renal failure, when the glomerular filtration rate is less than 10 ml/min (when the patient cannot excrete more than 1 liter of urine per day), fluid intake must be regulated according to diuresis (300-500 ml is added to the amount of urine excreted over the previous day).
2.4. Active methods of treating chronic renal failure
In the later stages of chronic renal failure, conservative treatment methods are ineffective, therefore, in the terminal stage of chronic renal failure, active treatment methods are carried out: continuous peritoneal dialysis, program hemodialysis, kidney transplantation.
2.4.1. Peritoneal dialysis
This method of treating patients with chronic renal failure consists of introducing a special dialysate solution into the abdominal cavity, into which, thanks to a concentration gradient, various substances contained in the blood and body fluids diffuse through the mesothelial cells of the peritoneum.
Peritoneal dialysis can be used in both early periods terminal stage, and in its final periods, when hemodialysis is impossible.
The mechanism of peritoneal dialysis is that the peritoneum plays the role of a dialysis membrane. The effectiveness of peritoneal dialysis is not lower than the effectiveness of hemodialysis. Unlike hemodialysis, peritoneal dialysis can also reduce the content of medium molecular weight peptides in the blood, since they diffuse through the peritoneum.
The technique of peritoneal dialysis is as follows. A lower laparotomy is performed and a Tenckhoff catheter is inserted. The end of the catheter, perforated for 7 cm, is placed in the pelvic cavity, the other end is removed from the anterior abdominal wall through the counter-aperture, and an adapter is inserted into the outer end of the catheter, which is connected to a container with a dialysate solution. For peritoneal dialysis, dialysate solutions are used, packaged in two-liter plastic bags and containing ions of sodium, calcium, magnesium, lactate in percentage, equivalent to their content in normal blood. The solution is changed 4 times a day - at 7, 13, 18, 24 hours. The technical simplicity of changing the solution allows patients to do it independently after 10-15 days of training. Patients easily tolerate the peritoneal dialysis procedure, they feel better quickly, and treatment can be carried out at home. A typical dialysate solution is prepared with a 1.5-4.35% glucose solution and contains sodium 132 mmol/L, chlorine 102 mmol/L, magnesium 0.75 mmol/L, calcium 1.75 mmol/L.
The effectiveness of peritoneal dialysis, carried out 3 times a week, lasting 9 hours, in terms of removal of urea, creatinine, correction of electrolyte and acid-base status, is comparable to hemodialysis, carried out three times a week for 5 hours.
There are no absolute contraindications to peritoneal dialysis. Relative contraindications: infection in the anterior abdominal wall, inability of patients to follow a diet with high content protein (such a diet is necessary due to significant losses of albumin with the dialysate solution - up to 70 g per week).
2.4.2. Hemodialysis
Hemodialysis is the main method of treating patients with acute renal failure and chronic renal failure, based on the diffusion from the blood into the dialysate solution through a translucent membrane of urea, creatinine, uric acid, electrolytes and other substances retained in the blood during uremia. Hemodialysis is carried out using an “artificial kidney” apparatus, which consists of a hemodialyzer and a device with the help of which the dialysate solution is prepared and supplied to the hemodialyzer. In the hemodialyzer, the process of diffusion of various substances from the blood into the dialysate solution occurs. The “artificial kidney” device can be individual for hemodialysis for one patient or multi-site, when the procedure is carried out simultaneously for 6-10 patients. Hemodialysis can be carried out in a hospital under the supervision of medical staff, in a hemodialysis center, or, as in some countries, at home (home hemodialysis). From an economic point of view, home hemodialysis is preferable; it also provides more complete social and psychological rehabilitation of the patient.
The dialysate solution is selected individually depending on the content of electrolytes in the patient’s blood. The main ingredients of the dialysate solution are as follows: sodium 130-132 mmol/l, potassium - 2.5-3 mmol/l, calcium - 1.75-1.87 mmol/l, chlorine - 1.3-1.5 mmol/l. No special addition of magnesium to the solution is required, because the level of magnesium in tap water is close to its content in the patient’s plasma.
To carry out hemodialysis over a significant period of time, constant reliable access to arterial and venous vessels is required. For this purpose, Scribner proposed an arteriovenous shunt - a method of connecting the radial artery and one of the veins of the forearm using Teflonosilastic. Before hemodialysis, the outer ends of the shunt are connected to the hemodialyzer. The Vreshia method has also been developed - the creation of a subcutaneous arteriovenous fistula.
A hemodialysis session usually lasts 5-6 hours and is repeated 2-3 times a week (programmed, permanent dialysis). Indications for more frequent hemodialysis arise when uremic intoxication increases. Using hemodialysis, you can extend the life of a patient with chronic renal failure by more than 15 years.
Chronic program hemodialysis is indicated for patients with end-stage chronic renal failure aged 5 (body weight more than 20 kg) to 50 years, suffering from chronic glomerulonephritis, primary chronic pyelonephritis, secondary pyelonephritis of dysplastic kidneys, congenital forms of ureterohydronephrosis without signs of active infection or massive bacteriuria, who agree to hemodialysis and subsequent kidney transplantation. Currently, hemodialysis is also performed for diabetic glomerulosclerosis.
Chronic hemodialysis sessions begin with the following clinical and laboratory indicators:
- glomerular filtration rate less than 5 ml/min;
- effective renal blood flow rate is less than 200 ml/min;
- urea content in blood plasma is more than 35 mmol/l;
- creatinine content in blood plasma more than 1 mmol/l;
- the content of “medium molecules” in the blood plasma is more than 1 unit;
- potassium content in blood plasma more than 6 mmol/l;
- decrease in standard blood bicarbonate below 20 mmol/l;
- deficiency of buffer bases more than 15 mmol/l;
- development of persistent oligoanuria (less than 500 ml per day);
- incipient pulmonary edema due to overhydration;
- fibrinous or less commonly exudative pericarditis;
- signs of increasing peripheral neuropathy.
Absolute contraindications to chronic hemodialysis are:
- cardiac decompensation with congestion in the systemic and pulmonary circulation, regardless of kidney disease;
- infectious diseases of any localization with an active inflammatory process;
- oncological diseases of any localization;
- tuberculosis of internal organs;
- gastrointestinal ulcer in the acute phase;
- severe liver damage;
- mental illness with a negative attitude towards hemodialysis;
- hemorrhagic syndrome of any origin;
- malignant arterial hypertension and its consequences.
During chronic hemodialysis, the diet of patients should contain 0.8-1 g of protein per 1 kg of body weight, 1.5 g of table salt, no more than 2.5 g of potassium per day.
With chronic hemodialysis, the following complications are possible: progression of uremic osteodystrophy, episodes of hypotension due to excessive ultrafiltration, infection with viral hepatitis, suppuration in the shunt area.
2.4.3. Kidney transplant
Kidney transplantation is the optimal method of treating chronic renal failure, which consists of replacing a kidney damaged by an irreversible pathological process with an unchanged kidney. The selection of a donor kidney is carried out according to the HLA antigen system; most often, a kidney is taken from identical twins, the patient’s parents, and in some cases from people who died in a disaster and are compatible with the patient according to the HLA system.
Indications for kidney transplantation: I and II periods of the terminal phase of chronic renal failure. Kidney transplantation is not advisable for persons over 45 years of age, as well as for patients diabetes mellitus, as they have reduced kidney graft survival.
The use of active treatment methods - hemodialysis, peritoneal dialysis, kidney transplantation - has improved the prognosis for terminal chronic renal failure and extended the life of patients by 10-12 and even 20 years.
