The fourth stage of renal failure. The problem of chronic renal failure: stages of the disease and treatment methods Classification of chronic renal failure

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Chronic renal failure, unspecified (N18.9)

Nephrology

general information

Short description

chronic renal failure- a syndrome of irreversible impairment of all renal functions lasting for months or years, leading to a disorder of water, electrolyte, nitrogen and other types of metabolism, caused by the development of sclerosis of the renal tissue due to various renal diseases.

CKD- kidney damage (microalbuminuria more than 30 mg/day, hematuria) or a decrease in their function for 3 months or more. The definition and classification of CKD was implemented by the National Kidney Foundation, National Kidney Foundation (NKF) and the Kidney Disease Outcomes Quality Initiative (KDOQI) in 2002.

Further discussion of the protocol is carried out according to the new classification of CKD.

I. INTRODUCTORY PART

Protocol name: Chronic renal failure (CRF)

Protocol code:

ICD codes:

N18 Chronic renal failure

N18.0 End-stage renal disease

N18.8 Other manifestations of chronic renal failure

N18.9 Chronic renal failure, unspecified

N19 Renal failure, unspecified

Abbreviations used in the protocol:

BP - blood pressure

BB - beta-adrenergic receptor blockers

CCBs - calcium channel blockers

ARBs - angiotensin receptor blockers

PEM - protein-energy malnutrition

VARMS - congenital anomalies of the urinary system

GP - general practitioner

HD - hemodialysis

HDF - hemodiafiltration

GF - hemofiltration

RRT - renal replacement therapy

ACE inhibitors - angiotensin-converting factor inhibitors

IP - artificial kidney

MI - myocardial infarction

MSRT - methods of renal replacement therapy

TIBC - total iron-binding capacity of serum

ACVA - acute cerebrovascular accident

AKI - acute renal failure

BCC - circulating blood volume

PTH - parathyroid hormone

GFR - glomerular filtration rate

ESRD - end-stage renal failure

EPO - erythropoietin

CKD - ​​chronic kidney disease

CRF - chronic renal failure

CAPD - continuous ambulatory peritoneal dialysis
CRF - chronic renal failure

HB - hemoglobin

Ca-P - phosphorus-calcium metabolism

Kt/V - parameters of dialysis adequacy

URR - residual urea fraction

Patient category: Patients aged 18 years and older with chronic renal failure, resulting from diabetic nephropathy, hypertensive nephroangiosclerosis, primary and/or secondary kidney disease (glomerular, tubulointerstitial, kidney damage due to systemic diseases, cystic kidney disease), congenital anomalies of the urinary system ( VARMS), and kidney transplant patients.

Protocol users: nephrologists, hemodialysis department specialists, urologists, therapists, cardiologists, endocrinologists, rheumatologists, resuscitators, GPs.

Classification

Clinical classification

Modern classification is based on two indicators - glomerular filtration rate (GFR) and signs of renal damage (proteinuria, albuminuria). Depending on their combination, five stages of CKD are distinguished.

International classification of CKD depending on GFR

CKD is diagnosed if there is kidney damage and/or a decrease in GFR ≤ 60 ml/min/1.73 m2 for 3 months or more. Kidney damage refers to structural and functional abnormalities of the kidneys identified by blood tests, urine tests, or imaging examinations.

CKD stages 3–5 correspond to the definition of chronic renal failure (decrease in GFR 60 or less ml/min).

Stage 5 corresponds to end-stage chronic renal failure (uremia).

Calculation of GFR in patients with CKD stages 1-3 is carried out using the Cockcroft-Gault formula; in CKD stages 4-5 it is calculated using the MDRD and CKD-EPI formulas or determined by the daily clearance of endogenous creatinine.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of diagnostic measures

List of diagnostic measures for CKD stages 1-3

Biochemical studies: creatinine, urea, blood electrolytes, glucose, total protein, albumin, protein fractions, serum iron, cholesterol

Parathyroid hormone, ferritin, transferrin iron saturation percentage

General urine analysis, urine analysis according to Nechiporenko

Protein/creatinine, protein/albumin coefficients

Electrophoresis of urine proteins (tubular, glomerular, selective proteinuria)

Blood pressure, height, weight, BMI

Calculation of GFR using the Cockcroft-Gault formula

Biochemical blood test: uric acid, glycemic profile, daily excretion of uric acid, alkaline phosphatase, GGTP, ALT, AST, lipid profile, complements (C3, C4), TBSS, transferrin, M-gradient, glycosylated hemoglobin, C-peptide, insulin , C-reactive protein

Immunological blood test for ANA, ENA, total nuclear antibodies, T3, T4, TSH, antibodies to TPO, c-ANCA, p-ANCA, anti-ds-DNA, anti-GBM, circulating immune complexes, ASLO, ASA, APL- antibodies, antibodies to cardiolipin

Virological examination: Wasserman reaction, ELISA and/or PCR for cytomegalovirus, herpes simplex virus types 1 and 2, viral hepatitis, HIV, Epstein-Barr virus, Polyomavirus, Parvovirus, Candida albicans

Procalcitonin, interleukin-18

Bence Jones protein in urine

Ultrasound of the abdominal organs, kidneys (lying and standing), adrenal glands and bladder with determination of residual urine

Doppler ultrasound of renal vessels

Dynamic nephroscintigraphy

ECG, EchoCG

Ophthalmoscopy

X-ray examination of bones

List of diagnostic measures for CKD stages 4-5

Basic laboratory and diagnostic measures:

Complete blood count (6 parameters), reticulocytes, percentage of hypochromic erythrocytes

Biochemical studies: creatinine (before and after HD session), urea (before and after HD session), potassium/sodium determination (before and after HD session), blood electrolytes, glucose, total protein, albumin, serum iron, cholesterol

Parathyroid hormone, ferritin, transferrin iron saturation percentage

Coagulogram 1 (prothrombin time, fibrinogen, thrombin time, APTT)

General urine analysis

Blood pressure, height, weight, BMI

Calculation of GFR using the MDRD and CKD-EPI formulas or determined by the daily clearance of endogenous creatinine

Additional laboratory and diagnostic measures:

Biochemical blood test: uric acid, ALT, AST, VT, transferrin, glycemic profile. glycosylated hemoglobin, C-reactive protein,

Immunological blood test for ANA, ENA, total nuclear antibodies, T3, T4, TTE, antibodies to TPO, c-ANCA, p-ANCA, anti-ds-DNA, anti-GBM, circulating immune complexes, aPL antibodies, antibodies to cardiolipin

Virological examination: Wasserman reaction, ELISA and/or PCR for cytomegalovirus, herpes simplex virus types 1 and 2, viral hepatitis, HIV, Epstein-Barr virus, Polyomavirus, Parvovirus, Candida albicans,

Culture of urine and other biomaterials on MT 3 times

Daily fluid balance (daily measurement of fluid intake and urine output)

Bacteriological examination and sensitivity to antibiotics of urine and other biomaterials

Instrumental research methods:

Ultrasound of the abdominal organs, pleural cavities, kidneys, adrenal glands and bladder with determination of residual urine

Doppler ultrasound of renal vessels

UDG AVF

X-ray of the chest organs

Excretory urography

ECG, EchoCG

Ophthalmoscopy

MRI, CT - according to indications (formation, cysts)

X-ray examination of bones, densitometry (for renal bone disease)

Patient's outpatient diary with recording of blood pressure and fluid balance

Kidney biopsy (if indicated)

The list of diagnostic measures for patients with stage 4-5 CKD in a hospital setting may vary and depends on the severity of the patient’s condition. In a hospital setting, all types of therapeutic and diagnostic measures can be carried out if the indications are justified and take into account the existing underlying and concomitant diseases within the framework of existing clinical protocols.

Complaints and anamnesis

Patients with stages 1-3 of CKD may have no complaints or may have complaints about the disease that led to CKD (arterial hypertension, diabetes mellitus, glomerulonephritis, etc.). An integral part of diagnosis is active identification, detailing of complaints and clarification of anamnestic data.

Patients with stage 4-5 CKD complain of weakness, fatigue, loss of appetite, nausea, vomiting, headaches, tinnitus, polyuria, polydipsia, decreased urine output, edema, retardation in physical development, pain in bones, muscles, skin itching.

History: long-term diabetes mellitus and/or arterial hypertension, primary and/or secondary kidney diseases (glomerular, tubulointerstitial, VARMS), systemic diseases, corrective surgeries on the urinary system.

Physical examination

Pale or pale earthy tint, dry skin, scratch marks on the skin, swelling, muscle wasting, asthenia, bone deformities, polyuria, oliguria, anuria, arterial hypertension, ammonia odor from the mouth.

Instrumental studies

Ultrasound of the kidneys (reduction in kidney size, with the exception of diabetic nephropathy, kidney transplant and polycystic kidney disease), changes in Dopplerography of the renal vessels (decrease/absence of linear blood flow velocities, increase in resistance indices of more than 0.7).
Ultrasound of the pleural cavities - fluid accumulation syndrome, ECG - signs of LV hypertrophy, electrolyte and metabolic disorders, myocardial dystrophy. Ophthalmoscopy - hypertensive, diabetic retinopathy, EchoCG - signs of heart failure (EF<60%), снижение сократимости, диастолическая дисфункция, перикардит, ФГДС - уремические гастропатии.
X-ray of the chest organs - uremic pleurisy, uremic and/or congestive pneumonia.
Densitometry - decrease in bone mineral density. Kidney biopsy - morphological signs of renal pathology.

Indications for consultation with specialists

Cardiologist - development of acute and chronic heart failure, cardiac arrhythmias, myocardial ischemia, pulmonary embolism

Ophthalmologist - changes in the fundus vessels with hypertension, diabetes, prolonged uremia or steroid use (angiopathy, cataracts)

Neurologist - development of uremic encephalopathy, peripheral neuropathy, carpal tunnel syndrome

Psychologist - psychological disorders (depression, anorexia, etc.) associated with long-term chronic illness, in preparation for transplantation

Anesthesiologist-resuscitator - if necessary, central vein catheterization for hemodialysis

Surgeon - for the formation of an arteriovenous fistula or implantation of a catheter for peritoneal dialysis, the presence of fluid in the pleural cavities, the presence of signs of acute surgical pathology

Rheumatologist - presence of signs of systemic pathology

Endocrinologist - presence of diabetes mellitus, thyroid diseases

Oncologist - presence of signs of cancer

Phthisatr - if tuberculosis is suspected

Urologist - presence of urinary tract obstruction

ENT doctor - inflammation of the paranasal sinuses, decompensated tonsillitis, if Wegener's syndrome is suspected, hearing loss with Alport's syndrome

Gastroenterologist - presence of pronounced manifestations of uremic gastroenteropathy

Infectious disease specialist - presence of hepatitis, acute and exacerbation of chronic infections

Gynecologist - identifying pathology in the pelvis

Hematologist - severe disseminated intravascular coagulation syndrome, aregenerative anemias

Laboratory diagnostics

Laboratory research:

Anemia (hemoglobin<130г/л у мужчин, <120г/л у женщин),
- decrease in blood ferritin,
- uremia (increased levels of urea (above 8 mmol/l) and creatinine (in terms of GFR (see point 10),
- hyperkalemia above 5.5 mmol/l,
- hypoproteinemia less than 60 g/l with hypoalbuminemia less than 35 g/l,
- disturbance of phosphorus-calcium metabolism (total calcium less than 2.1,

Hyperphosphatemia above 1.78 mmol/l,
- increase in CaxP value above 4.4 mmol2/l2,
- increased level of parathyroid hormone above 300 pg/ml (see paragraph 15.2.5 Bone disease in CKD)),
- disturbance of acid-base balance (metabolic acidosis Ph below 7.35),
- violation of the blood coagulation system (normal APTT -35-45 sec, INR -0.9 -1.1, PTI -90 -120%, fibrinogen 2-4 g/l, PTT - 16-17 sec),
- decrease in specific gravity of urine below 1018,
- pathological urinary sediment (proteinuria above 150 mg/day, the presence of hematuria, cylindruria).

Differential diagnosis

CKD should be differentiated from acute kidney injury.

Treatment abroad

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Treatment

Goal of treatment

For patients with CKD stages 1-3 - slowing the progression of CKD by treating the underlying disease that led to CKD, treating complications of CKD.

For patients with CKD stages 4-5 - preparation for renal replacement therapy, carrying out adequate dialysis therapy: from the start of introductory dialysis to achieving target values ​​(see Hemodialysis protocol), treatment of complications of CKD and dialysis therapy.

Treatment tactics

Non-drug treatment

Mode: The regimen of patients with CKD in a hospital setting depends on the severity of the condition.

Diet: correction of malnutrition, for patients with CKD stages 2-3 - a low-protein diet (15) in order to slow down the rate of progression of CKD.

Malnutrition is the common and most visible complication of CKD in patients and leads to increased hospitalization and mortality rates

Principles of diet therapy in patients with CKD

Replenishment of energy needs in patients with CKD should be calculated depending on the age and stage of CKD (predialysis, dialysis).

There is no need to limit the protein intake of patients in the pre-dialysis stages of CKD, if it does not exceed the daily requirement.

In case of poor nutrition, as well as during dialysis treatment, the possibility of additional administration of vitamins (folic acid, vitamins B, C, L-carnitine) should be taken into account.

Patient education involves calculating daily energy requirements using tables.

If independent nutrition is insufficient and there is a pronounced BMI deficiency, take into account feeding through a nasogastric tube.

Correction of sodium and fluid balance

Patients with CKD due to obstructive uropathy or renal dysplasia in polyuria (salt-wasting variant) often require additional sodium chloride up to 4-7 mEq/kg/day

Patients with CKD due to primary glomerular diseases or oliguria need to limit salt and fluid intake to reduce the risk of developing edema and hypertension. It is recommended to limit the intake of table salt to 1.5 g/day.

Correction of acidosis

According to the literature, chronic acidosis in patients with CKD is associated with accelerated progression of renal failure and high mortality.

The standard treatment for metabolic acidosis in patients with CKD is oral sodium bicarbonate (baking soda) at a rate of 1-3 mmol/kg/day.

Drug treatment

Correction of arterial hypertension

Arterial hypertension is one of the most important independent risk factors for the progression of CKD. Great care must be taken to measure blood pressure correctly. The target blood pressure level for CKD is ≤ 140/90 mm Hg, in the presence of microalbuminuria/proteinuria ≤ 130/80 mm Hg. In stages 4-5 of CKD, loop diuretics are used. Antihypertensive drugs are angiotensin 2 receptor blockers, beta blockers, calcium channel blockers. The dose of the drug should be selected taking into account the GFR.

Correction of renal anemia:

Anemia is one of the early and most common complications of CKD. According to the latest revision of the KDIGO-2012 anemia guidelines, the diagnosis of anemia with CKD is based on the hemoglobin level< 130г/л у мужчин и < 120 г/л у женщин.

Definition of anemia and target hemoglobin in patients with CKD

Key elements in the treatment of anemia in CKD are the use of erythropoietin-stimulating agents, such as recombinant human erythropoietin (epoetin alfa, epoetin beta, darbepoetin, epoetin theta, methoxypolyethylene glycol-epoetin beta), and iron supplements. According to modern literature data, early use of erythropoietin in patients with CKD improves appetite, exercise tolerance, oxygen absorption, and quality of life.

Initial dose of erythropoietin: 100-150 IU/kg per week subcutaneously, divided into 2-3 injections at intervals. Patients often require a 50-100% increase in the starting dose (150 IU/kg per week subcutaneously). The goal of treatment is to achieve a monthly increase in hemoglobin levels by 10-20 g/l until the target level is reached (115 g/l). The EPO dose should be increased by 25% if anemia persists and the hemoglobin level has not increased by 10 g/l after 1 month of treatment. The EPO dose should be reduced by 25% if the hemoglobin level exceeds the target level or the rate of increase is more than 20 g/l per month. A condition in which the target hemoglobin level is not achieved at an EPO dose of more than 500 IU/kg per week is called resistance to EPO treatment.

Initial doses of epoetins in patients with CKD

In patients with CKD, parenteral iron supplements should be used only, given the high levels of hepcidin in patients with CKD, which interferes with the absorption of iron from the intestinal lumen. Iron preparations used parenterally for iron correction in patients with stage 4-5 CKD:

Iron III dextran hydroxide, for parenteral administration

Iron III hydroxide sucrose complex for parenteral administration

Target values ​​for iron therapy in patients with CKD

In cases where there is no effect from therapy with jelly and EPO drugs, the following reasons must be excluded:

Easily adjustable:

Absolute iron deficiency

Deficiency of B12, folate

L-carnitine deficiency

Hypothyroidism

Use of ACE inhibitors

Hyperparathyroidism

Lack of adherence to treatment

Breaks in treatment

Potentially adjustable:

Infection/inflammation

Underdialysis

Hemolysis/bleeding

Hyperparathyroidism

Partial red cell aplasia of the bone marrow

Tumors

Protein-energy malnutrition

Non-adjustable:

Hemoglobinopathies

Bone marrow pathology

Renal bone disease (mineral bone disorders in CKD)

Renal bone disease is a severe complication of CKD, and early correction of serum calcium, phosphorus, and PTH levels is necessary.

Target levels of parathyroid hormone depending on the stages of CKD

In order to correct hyperphosphatemia, it is necessary to use phosphate binders, depending on the phosphorus consumed with food: calcium-containing (cholecalciferol up to 3 g/day), as well as calcium-free (Sevelamer carbonate 3-6 tablets/day). Phosphate binders should be taken with meals.

For the treatment of secondary hyperparathyroidism, only after correction of hyperphosphatemia it is necessary to use active forms of vitamin D (Alfacalcidol, Cinacalcet, Paricalcitol). The dose is selected depending on the initial PTH level and the stage of CKD and under strict control of phosphorus and PTH levels. If drug correction of secondary hyperparathyroidism is ineffective, indications for parathyroidectomy and hardening of the parathyroid glands are given.

Correction of hyperkalemia

Possible causes and treatment principles for hyperkalemia:

The presence of hyperkalemia in combination with a relatively high creatinine level in patients with CKD, obstructive uropathy, reflux nephropathy or interstitial nephritis. A common cause is insufficient fluid intake. Treatment: replacement of fluid and sodium losses

Taking potassium-sparing diuretics, ACE inhibitors, ARBs. Treatment: reduce doses or eliminate the drug.

In case of persistent hyperkalemia, exclude foods rich in potassium from the diet (for example, chocolate, potatoes, herbs, fruits, dried fruits, juices, compotes), teach the patient and his family about this diet

All patients with stage 4-5 CKD in a hospital setting must be assessed for acid-base balance according to indications to exclude hyperkalemia associated with severe acidosis.

Severe hyperkalemia requires drug treatment. Correction of hyperkalemia begins at plasma potassium levels >5.5 mmol/l:

1) Intravenous administration of 4% sodium bicarbonate solution 1-2 ml/kg for 20 minutes under the control of the acid-base state of the blood - onset of action in 5-10 minutes, duration of action 1-2 hours.

2) Intravenous administration of 20% glucose at 1-2 g/kg with insulin - onset of action in 30-60 minutes, duration of action 2-4 hours.

3) Intravenous slow administration of 10% calcium gluconate solution 0.5-1.0 ml/kg with monitoring of the number of heart contractions. Repeated administration until changes on the ECG disappear - the onset of action is immediate, the duration of action is 30-60 minutes.

4) Salbutamol inhalation.

5) Hemodialysis, peritoneal dialysis.

For treatment of other complications and conditions associated with comorbidities that increase the severity and prognosis of patients with CKD, see appropriate protocols.

Other treatments

Dialysis therapy - see Hemodialysis protocol

Surgical intervention in a hospital setting

To ensure adequate vascular access for the purpose of high-quality blood purification from uremic toxins:

Implantation of a temporary dialysis catheter (for emergency indications)

Formation/removal of AVF (for program hemodialysis)

Suturing/excision of AVF aneurysm

Implantation/explantation of a synthetic vascular prosthesis

Implantation/explantation of a permanent catheter

For peritoneal dialysis -

Implantation/explantation of a peritoneal catheter (for peritoneal dialysis)

For morphological verification -

Kidney biopsy

For massive hematuria and proteinuria:

Nephrectomy unilateral

Nephrectomy bilateral

For surgical treatment of hyperparathyroidism not corrected by medications

Parathyroidectomy

Sclerosation of the parathyroid glands.

Preventive actions:

Preventing the above complications

Patient education on diet, prevention of infectious complications during peritoneal dialysis.

Monitoring blood pressure at home with diary entries

Before starting renal replacement therapy, patients should be screened for viral infections, in particular viral hepatitis (B and C).

Patients who are positive for viral hepatitis B and C should receive dialysis therapy in a separate room, on a separate artificial kidney machine to prevent the spread of infection.

Patients who have not previously been vaccinated and are not infected with viral hepatitis should be vaccinated against viral hepatitis B before starting program dialysis.

Further management

Monitoring and rehabilitation of patients with CKD stages 1-3 is carried out by local therapists and GPs at the place of residence with the involvement of specialized specialists.

Patients suffering from stage 4-5 CKD require lifelong renal replacement therapy (peritoneal dialysis, hemodialysis, kidney transplantation). All patients receiving dialysis therapy are prepared for a donor kidney transplant as soon as possible. Those

Patients who started treatment with peritoneal dialysis, if the treatment is not adequate due to loss of function of the peritoneal peritoneum, are transferred to hemodialysis. Patients receiving hemodialysis therapy, if it is impossible to continue hemodialysis due to the problem of maintaining and creating vascular access, can be transferred to peritoneal dialysis (in the absence of any contraindications).

3. Progressive hyperazotemia (symptoms of uremia);

4. Uncontrolled arterial hypertension;

5. Severe progressive anemia (renal and/or posthemorrhagic);

6. If complications occur with vascular access or peritoneal access;

7. Other complications requiring emergency treatment.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67:2089. 2. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis, 2002, T.2 Suppl.1. P.1 - 246 3. Jander A, Nowicki M, Tkaczyk M et al. Does a late referral to a nephrologist constitute a problem in children starting renal replacement therapy in Poland? – A national study. Nephrol Dial Transplant. 2006 Apr;21(4): 957-961. 4. Wuhl E, Schaefer F. Therapeutic strategies to slow chronic kidney disease progression. Pediatr Nephrol 2008; 23: 705-716 5. Mattoo TK. Epidemiology, risk factors, and etiology of hypertension in children and adolescents. In UpToDate Online 16.1. UpToDate1, Inc. Niaudet P (eds.). 2008 6. Association IPH: Blood Pressure Limits Chart. In, 2008 http://www.pediatrichypertension.org/BPLimitsChart.pdf 7. Strict blood-pressure control and progression of renal failure in children. ESCAPE Trial Group, Wuhl E, Trivelli A, Picca S et al. N Engl J Med. 2009 Oct22; 361(17): 1639-50 8. Rene G. VanDeVoorde, Bradley A. Warady. Management of Chronic Kidney Disease, from Pediatric Nephrology; 1676-1677; Springer 2009 9. Clinical practice recommendations for anemia in chronic kidney disease in children. Am J Kidney Dis 2006;47:86–108. 10. Rene G. VanDeVoorde, Bradley A. Warady. Management of Chronic Kidney Disease, from Pediatric Nephrology; 1666-1670; Springer 2009 11. Boehm M, Riesenhuber A, Winkelmayer WC, Arbeiter K, Mueller T, Aufricht C. Early erythropoietin therapy is associated with improved growth in children with chronic kidney disease. Pediatr Nephrol. 2007 Aug;22(8):1189-93 12. Jabs K. the effect of recombinant human erythropoietin on growth and nutritional status. Pediatr Nephrol 1996; 10: 324-327 13. Gerson A, Hwang W, Fiorenza J et al. Anemia and health-related quality of life in adolescents with chronic kidney disease. Am J Kidney Dis. 2004; 44: 1017-1023 14. On approval of the nomenclature, rules for procurement, processing, storage, sale of blood and its components, as well as rules for storage, transfusion of blood, its components and preparations. Acting order Minister of Health of the Republic of Kazakhstan dated November 6, 2009 No. 666. 15. Strivaths PR, Wong C, Goldstein SL. Nutrition aspects in children receiving maintenance hemodialysis: impact on outcome. Pediatr Nephrol 2008 Feb 22 16. Foster BJ, McCauley L, Mak RH. Nutrition in infants and very young children with chronic kidney disease. Pediatr Nephrol. 2011 Aug 28. 17. Wingen AM, Fabian-Bach C, Schaefer F et al. Randomized multi-centre study of a low-protein diet on the progression of chronic renal failure in children. European Study Group of Nutritional Treatment of Chronic Renal Failure in Childhood. Lancet 1997; 349: 1117-1123 18. Pereira AM, Hamani N, Nogueira PC, Carvalhaes JT. Oral vitamin intake in children receiving long-term dialysis. J Ren Nutr. 2000 Jan;10(1): 24-9 19. Kucher A.G., Kayukov I.G., Yesayan E.M., Ermakov Yu.A. Handbook on poultry for patients with chronic renal failure. St. Petersburg, 2004. 20. Lesley Ress, Vanessa Shaw. Nutrition in children with CRF and on dialysis. Pediatr Nephrol. 2007; 22:1689 - 1702 21. Mehls O, Wuhl E, Tonshoff B et al. Growth hormone treatment in short children with chronic kidney disease. Acta Paediatr. 2008 Sep; 97(9): 1159-64 22. Katherine Wesseling-Perry, Isidro B. Salusky. chronic Kidney Disease Mineral ans Bone Disorder, from Pediatric Nephrology; 1755 – 1783; Springer 2009 23. National Kidney Foundation. K/DOQI clinical pracrice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003 Oct; 42(4 Suppl 3):S1-201 24. Shah SN, Abramowitz M, Hostetter TH et al. Serum bicarbonate level and the ptogression of Kidney Disease: A Cohort Study. Am J Kidney Disease, Vol 54 No 2, 2009:270-277 25. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis 2000;35:S1–140. 26. Seikaly MG, Salhab N, Browne R. Patterns and time of initiation of dialysis in US children. Pediatr Nephrol 2005; 20:982-988 27. National Kidney Foundation. K/DOQI. 2006 updates clinical practice guidelines and recommendations. http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_Guidelines-HD_Oct06_SectionA_ofC.pdf 28. KDIGO for Anemia in Chronic Kidney Disease. 2012

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers
Tuganbekova S.K. - Deputy Director for Science of JSC “NNMC”, Doctor of Medical Sciences, Professor, Chief Freelance Nephrologist of the Ministry of Health of the Republic of Kazakhstan
Narmanova O.Zh. - Professor of the Department of GP No. 2 of JSC "MUA", Doctor of Medical Sciences, independent accredited expert, nephrologist of the highest category
Gaipov A.E. - Head of the OEKGK JSC "NNMC", nephrologist, Ph.D.
Smailov Zh.T. - chief freelance specialist in hemodialysis at the Ultrasonics Department of Astana, doctor of the highest category
Kokoshko A.I. - JSC "MUA" Associate Professor of the Department of Anesthesiology and Reanimatology, Ph.D.

Reviewers:

Karabaeva Aigul Zhumartovna - Doctor of Medical Sciences, Director of the Center for Postgraduate and Additional Professional Education of the Research Institute of K and VB, Almaty

Conflict of interest No.

Specifying the conditions for reviewing the protocol: Next revision: no later than 3 years from the date of this approval or when new proven data becomes available.

Attached files

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What is it - kidney failure is a serious functional disorder of the kidneys that leads to water, electrolyte and acid-base imbalances in the body.

Renal failure is characterized by a sharp decrease in the amount of urine excreted by the kidneys, up to its complete absence for 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.

AKI can occur as a result of shock of various origins, the harmful effects of poisons and toxic substances, infections, kidney diseases, and 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 as a result of diseases of the kidneys 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, chronic renal failure has 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 functioning 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 kidney function is restored through 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 at balancing 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.

1. 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.

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.

2. 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.
3. 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 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

Renal failure is a pathological condition of the 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:

4. 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).
5. 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.
6. Postrenal, that is, as a result of acute bilateral blockage of the ureters due to urolithiasis.

The causes of chronic renal failure are considered to be chronic glomerulonephritis and pyelonephritis, systemic diseases, urolithiasis, 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:

7. Signs of renal failure in the initial phase: decreased amount of urine, decreased blood pressure, increased heart rate.
8. 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.
9. 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.
10. Renal failure of the 4th degree consists in the normalization of urine output, kidney function returns to normal after 1.5-3.5 months.

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 seek medical help. 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 there is a high concentration of 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.

11. Take lingonberry leaves, chamomile, motherwort herb, string flowers, dandelion and violet, half a teaspoon each. This collection is poured into a glass of boiled water, left for about 1 hour and taken a third of a glass 5 times a day.
12. Second recipe: mix mint, St. John's wort, lemon balm, calendula 1 tbsp. l. In a saucepan, add 2 cups of boiled water to the herbal mixture and bring to a boil. Pour the prepared infusion into a thermos and leave overnight. Take 100 ml per day.
13. Treatment with folk remedies for kidney failure includes the use of watermelon rinds, which have 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.
14. 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.

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:

15. It is necessary to limit protein intake to 65 g per day, depending on the phase of kidney disease.
16. The energy value of food increases due to increased consumption of fats and carbohydrates.
17. 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.
18. Proper culinary processing of products is carried out to improve appetite.
19. 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.

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 result, all important kidney functions are disrupted - 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 surgery or injury. About 40% of cases of the disease occur during the treatment of patients in a hospital. 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, injuries, 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 an injury to the ureter 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.

Kidney failure also develops as a result of postpartum hemorrhage, as well as preeclampsia in the last weeks of 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. There may also be loose stools 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 are possible. 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.

A particularly serious condition is caused by the terminal stage of 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 of 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 in the early stages of the disease.

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

In order to prevent the development of such a dangerous condition of the body, first of all, it is necessary to provide timely qualified assistance to those patients who have a high risk of developing acute renal failure. These are people with severe injuries, burns; those who have just undergone a major operation, 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, compared with Western medicine, will be able to nourish the kidneys, refrain from inflammation, accelerate the addition of nutrients to repair damaged (not completely damaged) kidney cells, and accompanying the correction of the kidneys, clinical symptoms/complications will be better under control 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 dietitian. And the dietician will provide a dietary plan that is based on the personal laboratory result and the underlying disease situation. 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.

According to the clinical course, acute and chronic renal failure are distinguished.

Acute renal failure

Acute renal failure develops suddenly, as a consequence of acute (but most often reversible) damage to the kidney tissue, and is characterized by a sharp drop in the amount of urine excreted (oliguria) to its complete absence (anuria).

Causes of acute renal failure

Symptoms of acute renal failure

• small amounts of urine (oliguria);
• complete absence (anuria).

The patient's condition worsens, this is accompanied by nausea, vomiting, diarrhea, lack of appetite, swelling of the extremities occurs, and the liver increases in volume. The patient may be inhibited or, on the contrary, agitation may occur.

In the clinical course of acute renal failure, several stages are distinguished:

Stage I- initial (symptoms caused by the direct impact of the cause that caused acute renal failure), lasting from the moment of exposure to the main cause until the first symptoms of the kidneys have a different duration (from several hours to several days). Intoxication may appear (pallor, nausea,);

Stage II- oligoanuric (the main symptom is oliguria or complete anuria, also characterized by a severe general condition of the patient, the occurrence and rapid accumulation of urea and other end products of protein metabolism in the blood, causing self-poisoning of the body, manifested by lethargy, adynamia, drowsiness, diarrhea, arterial hypertension, tachycardia , body edema, anemia, and one of the characteristic signs is progressively increasing azotemia - an increased content of nitrogenous (protein) metabolic products in the blood and severe intoxication of the body);

Stage III- restorative:

• early diuresis phase - the clinic is the same as in stage II;
• the phase of polyuria (increased urine production) and restoration of the concentrating ability of the kidneys - renal functions are normalized, the functions of the respiratory and cardiovascular systems, the digestive canal, the support and movement apparatus, and the central nervous system are restored; the stage lasts about two weeks;

IV stage- recovery - anatomical and functional restoration of renal activity to initial parameters. It can take many months, sometimes it takes up to one year.

Chronic renal failure

Chronic renal failure is a gradual decline in kidney function until it disappears completely, caused by the gradual death of kidney tissue as a result of chronic kidney disease, the gradual replacement of kidney tissue with connective tissue and shrinkage of the kidney.

Chronic renal failure occurs in 200-500 out of every million people. Currently, the number of patients with chronic renal failure is increasing annually by 10-12%.

Causes of chronic renal failure

The causes of chronic renal failure can be various diseases that lead to damage to the renal glomeruli. This:

• kidney diseases: chronic glomerulonephritis, chronic pyelonephritis;
• metabolic diseases diabetes mellitus, gout, amyloidosis;
• congenital kidney diseases, polycystic disease, underdevelopment of the kidneys, congenital narrowing of the renal arteries;
• rheumatic diseases, scleroderma, hemorrhagic vasculitis;
• vascular diseases arterial hypertension, diseases leading to impaired renal blood flow;
• diseases leading to disruption of the outflow of urine from the kidneys: urolithiasis, hydronephrosis, tumors leading to gradual compression of the urinary tract.

The most common causes of chronic renal failure are chronic glomerulonephritis, chronic pyelonephritis, diabetes mellitus and congenital anomalies of kidney development.

Symptoms of chronic renal failure

There are four stages of chronic renal failure.

1. Latent stage. At this stage, the patient may not have any complaints, or fatigue during physical activity, weakness that appears in the evening, and dry mouth may occur. A biochemical blood test reveals slight disturbances in the electrolyte composition of the blood, sometimes protein in the urine.
2. Compensated stage. At this stage, the patients’ complaints are the same, but they occur more often. This is accompanied by an increase in urine output to 2.5 liters per day. Changes are detected in the biochemical parameters of blood and in.
3. Intermittent stage. Kidney function is further reduced. There is a persistent increase in the blood products of nitrogen metabolism (protein metabolism), an increase in the level of urea and creatinine. The patient experiences general weakness, fatigue, thirst, dry mouth, appetite decreases sharply, an unpleasant taste in the mouth is noted, nausea and vomiting appear. The skin acquires a yellowish tint, becomes dry and flabby. Muscles lose tone, small muscle twitching, tremors of fingers and hands are observed. Sometimes there is pain in the bones and joints. The patient may have a much more severe course of common respiratory diseases, sore throats, and pharyngitis.

   During this stage, periods of improvement and deterioration in the patient's condition may be expressed. Conservative (without surgical intervention) therapy makes it possible to regulate homeostasis, and the general condition of the patient often allows him to still work, but increased physical activity, mental stress, errors in diet, restriction of drinking, infection, surgery can lead to deterioration of kidney function and aggravation of symptoms.

4. Terminal (final) stage. This stage is characterized by emotional lability (apathy is replaced by excitement), disturbance of night sleep, daytime drowsiness, lethargy and inappropriate behavior. The face is puffy, gray-yellow in color, the skin is itchy, there are scratches on the skin, the hair is dull and brittle. Dystrophy increases, and hypothermia (low body temperature) is characteristic. No appetite. The voice is hoarse. There is an ammonia smell from the mouth. Aphthous stomatitis occurs. The tongue is coated, the abdomen is swollen, vomiting and regurgitation are often repeated. Often - diarrhea, foul-smelling, dark-colored stools. The filtration capacity of the kidneys drops to a minimum.

   The patient may feel satisfactory for several years, but at this stage the amount of urea, creatinine, and uric acid in the blood is constantly increased, and the electrolyte composition of the blood is disturbed. All this causes uremic intoxication or uremia (uremia urine in the blood). The amount of urine excreted per day decreases until it is completely absent. Other organs are affected. Cardiac muscle dystrophy, pericarditis, circulatory failure, and pulmonary edema occur. Disorders of the nervous system are manifested by symptoms of encephalopathy (sleep disturbances, memory, mood, and the occurrence of depressive states). The production of hormones is disrupted, changes occur in the blood coagulation system, and immunity is impaired. All these changes are irreversible. Nitrogenous waste products are excreted in sweat, and the patient constantly smells of urine.

Prevention of kidney failure

Prevention of acute renal failure comes down to preventing the causes that cause it.

Prevention of chronic renal failure comes down to the treatment of such chronic diseases as: pyelonephritis, glomerulonephritis, urolithiasis disease.

Forecast

With timely and correct application of adequate treatment methods, most patients with acute renal failure recover and return to normal life.

Acute renal failure is reversible: the kidneys, unlike most organs, are able to restore completely lost function. However, acute renal failure is an extremely serious complication of many diseases, often foreshadowing death.

However, in some patients, the decrease in glomerular filtration and the concentrating ability of the kidneys remains, and in some, renal failure takes a chronic course, with associated pyelonephritis playing an important role.

In advanced cases, death in acute renal failure most often occurs from uremic coma, hemodynamic disorders and sepsis.

Chronic kidney failure must be monitored and treated early in the disease, otherwise it can lead to complete loss of kidney function and require a kidney transplant.

What can you do?

The main task of the patient is to notice in time the changes that occur to him both in terms of his general well-being and in the amount of urine, and consult a doctor for help. Patients who have a confirmed diagnosis of pyelonephritis, glomerulonephritis, congenital kidney anomalies, or systemic disease should be regularly monitored by a nephrologist.

And, of course, you must strictly follow the doctor’s instructions.

What can a doctor do?

The doctor will first determine the cause of kidney failure and the stage of the disease. After which all necessary measures will be taken to treat and care for the patient.

Treatment of acute renal failure is aimed primarily at eliminating the cause that causes this condition. Measures are applicable to combat shock, dehydration, hemolysis, intoxication, etc. Patients with acute renal failure are transferred to the intensive care unit, where they receive the necessary assistance.

Treatment of chronic renal failure is inseparable from treatment of the kidney disease that led to kidney failure.

Definition

Chronic renal failure (CRF) is the final stage of various first or secondary chronic kidney diseases, which leads to a significant decrease in the number of active nephrons due to the death of most of them. With chronic renal failure, the kidneys lose the ability to perform their excretory and incretory functions.

Causes

The most important causes of CKD (more than 50%) in adulthood are diabetes and hypertension. Therefore, they can often be detected by a general practitioner, family doctor, endocrinologist or cardiologist. In the presence of microalbuminuria and if CKD is suspected, patients should be referred to a nephrologist for consultation and treatment adjustment. Having reached the GFR level< 30 мл/мин/1,73 м 2 , пациенты обязательно должны консультироваться с нефрологом.

In nephrology, there are 4 groups of risk factors that influence the development and course of CKD. These are factors that may influence the development of CKD; factors that initiate CKD; factors that lead to the progression of CKD and risk factors for the final stage of CKD.

Significant progress has now been made in uncovering the pathogenetic mechanisms of progression of chronic kidney diseases. In this case, special attention is paid to the so-called non-immune factors (functional-adaptive, metabolic, etc.). Such mechanisms operate to varying degrees in chronic kidney damage of any etiology; their significance increases as the number of active nephrons decreases, and it is these factors that largely determine the rate of progression and outcome of the disease.

Symptoms

1. Damage to the cardiovascular system: hypertension, pericarditis, uremic cardiopathy, cardiac rhythm and conduction disorders, acute left ventricular failure.

2. Neurotic syndrome and damage to the central nervous system:

• uremic encephalopathy: symptoms of asthenia (increased fatigue, memory impairment, irritability, sleep disturbance), symptoms of depression (depressed mood, decreased mental activity, suicidal thoughts), phobias, changes in character and behavior (weakness of emotional reactions, emotional coldness, indifference, eccentric behavior) , disturbance of consciousness (stupor, stupor, coma), vascular complications (hemorrhagic or ischemic strokes);
• uremic polyneuropathy: flaccid paresis and paralysis, other changes in sensitivity and motor function.

3.Gastrointestinal syndrome:

• damage to the mucous membranes (cheilitis, glossitis, stomatitis, esophagitis, gastropathy, enteritis, colitis, stomach and intestinal ulcers);
• organic lesions of the glands (mumps, pancreatitis).

4.Amemic-hemorrhagic syndrome:

• anemia (normochromic, normocytic, sometimes erythropoietin deficiency or iron deficiency), lymphopenia, thrombocytopathy, minor thrombocytopenia, pale skin with a yellowish tint, dryness, signs of scratching, hemorrhagic rash (petechiae, ecchymosis, sometimes purpura).

5. Clinical manifestations caused by metabolic disorders:

• endocrine disorders (hyperparathyroidism, impaired libido, impotence, inhibition of spermatogenesis, gynecomastia, oligo- and aminorrhea, infertility);
• pain and weakness of skeletal muscles, cramps, proximal myopathy, ossalgia, fractures, aseptic bone necrosis, gout, arthritis, intradermal and measured calcifications, deposition of urea crystals in the skin, ammonia odor from the horn, hyperlipidemia, carbohydrate intolerance.

6.Immune system disorders: tendency to intercurrent infections, decreased antitumor immunity.

Timely identification of patients with impaired renal function is one of the main factors determining treatment tactics. Indicators of increased levels of urea and creatinine oblige the doctor to further examine the patient in order to establish the cause of azotemia and prescribe rational treatment.

Signs of chronic renal failure

1.Early signs:

• clinical: polyuria with nocturia in combination with hypertension and normochromic anemia;
• laboratory: decreased concentrating ability of the kidneys, decreased filtration function of the kidneys, hyperphosphatemia and hypocalcemia.

2.Late signs:

• laboratory: azotemia (increased creatinine, urea and serum uric acid);
• instrumental: reduction of the cortex of both kidneys, reduction in the size of the kidneys according to ultrasound or plain uroroentgenogram;

• Calt-Cockrof method;
• classic, with determination of the concentration of creatinine in plasma, its daily excretion in urine and minute diuresis.

Note : The most accurate methods for determining GFR are radiological with inulin iothalamate, DTPA, EDTA. Can be used:

Persistent normochromic anemia in combination with polyuria and hypertension should alert the doctor to the possibility of chronic renal failure in the patient. The following most informative tests help in differential diagnosis: determination of the maximum relative density and osmolarity of urine, the value of CF, the ratio of urea and creatinine in the blood, radionuclide data.

A decrease in the RF reserve (functional renal reserve - FR) due to nephropathy is considered as an early sign of impaired renal filtration function. In a healthy person after an acute load of protein or CP increases by 10-39%. A decrease or complete absence of FNR indicates hyperfiltration in functioning nephrons and should be regarded as a risk factor for the progression of chronic renal failure.

Depression of the maximum relative density of urine below 10 18 in the Zemnitsky test next to a decrease in CF (daily diuresis of at least 1.5 liters) below 60-70 ml/min. and the absence of FNR indicate the initial stage of chronic renal failure.

According to the differential diagnosis of acute renal failure, chronic renal failure is indicated by a history of kidney damage, polyuria with nocturia, stable hypertension, as well as a decrease in the size of the kidneys according to ultrasound or x-ray of the kidneys.

Diagnostics

Patients with chronic kidney disease (chronic kidney failure) need to undergo various tests for treatment. Patients are referred for diagnosis if they have symptoms such as, for example, signs of anemia, swelling, smell of urine, hypertension, and also for patients with diabetes, a mandatory check-up with a specialist is necessary.

Laboratory tests play an important role in treating symptoms of chronic renal failure. An important substance that determines the presence of a problem in the kidneys: creatinine. Determining creatinine is one of many routine tests. This is followed by blood and urine tests to determine kidney function. Using this information, you can calculate the so-called creatinine clearance, which allows you to accurately diagnose kidney function and thus prescribe the necessary treatment.

Other imaging methods are also used to diagnose chronic renal failure: these include ultrasound, computed tomography (CT) and X-ray contrast studies. In addition, such studies allow you to monitor the progress of chronic renal failure.

Prevention

Conservative treatment of chronic renal failure

Conservative remedies and treatment measures are used at degrees I-II and (level CF< 35 мл/мин.). На III-IV степенях прибегают к заместительной почечной терапии (хронический гемодиализ , перитонеальный диализ, гемосорбция, трансплантация почки).

The principles of conservative treatment of chronic renal failure include:

• rational diet;
• ensuring water-salt and acid-base balance;
• control blood pressure to avoid both an increase and a sharp decrease;
• correction of renal anemia;
• prevention of hyperparathyroidism;
• the use of procedures and drugs that remove nitrogenous waste from the gastrointestinal tract;
• treatment of osteodystrophy and acute infectious complications of chronic renal failure.

Rational diet and ensuring water-salt and acid-base balance

The choice of diet is determined by the degree of chronic renal failure and is based on the restriction of protein, sodium and liquid in the daily diet. The diet should be low in protein, low in calories and high in calories (not less than 2000 kcal/day).

Malobilkov diet (MBD)

Significantly improves the patient's condition with chronic renal failure and slows down the progression of chronic renal failure. First, even before the azotemic stage, at an EF level of 40 ml/min, it is recommended to reduce protein intake to 40-60 g per day. At stages I-II of chronic renal failure, you should consume 30-40 g of protein per day. And only if the EF decreases to 10–20 ml/min. and an increase in serum creatinine to 0.5-0.6 mmol/l. A rigid MBD is useful when the amount of protein is reduced to 20-25 g per day. In this case, the total calorie content is maintained mainly by carbohydrates, and instead of essential amino acids, special supplements are recommended. However, due to the high cost of these drugs in our country, patients are often advised to eat one egg per day.

A 1:3 mixture of eggs and potatoes has a ratio of essential amino acids close to the optimal ratio. If proteinuria is significant, the amount of protein in the diet is increased according to this loss, at the rate of one chicken egg for every 6 g of urine protein. Patients with chronic renal failure are recommended to replace half of the required daily protein with soy supplements and add fish oil.

The effectiveness of MBD is assessed by a decrease in uremic intoxication, dyspeptic symptoms, a decrease in the level of phosphates, urea, creatinine, the absence of hypoalbuminemia, hypotransferinemia, lymphopemia, hyperkalemia, stability of blood pH and bicarbonate levels.

Contraindications to MBD:

• sharp decrease in residual function (RF< 5мл/мин.);
• acute infectious complications of chronic renal failure;
• anorexia, cachexia (body weight< 80%);
• uncontrolled (malignant) hypertension;
• severe nephrotic syndrome;
• uremia (oliguria, pericarditis, polyneuropathy).

Patients with chronic renal failure without extrarenal manifestations of nephrotic syndrome, cardiovascular failure and with correctable hypertension receive 4-6 g of salt per day.

Calcium-rich foods (cauliflower, cucumber and orange juices) and alkaline mineral waters are introduced into the diet.

The amount of fluid should correspond to daily diuresis at a level of 2-3 liters, which helps reduce the reabsorption of metabolites and their excretion.

With a decrease in urine formation, fluid intake is adjusted depending on diuresis: it is 300-500 ml. exceed the amount of urine excreted over the previous day, the occurrence of oligo- or anuria, which leads to overhydration of the body, use chronic hemodialysis.

During treatment of chronic renal failure, correction of electrolyte disturbances is necessary. Potassium metabolism disorders are unsafe for the patient's life. For hypokalemia, potassium chloride is prescribed.

Chronic renal failure never occurs “by itself” - this pathology is a complication of many kidney diseases. But if we talk about the symptoms of chronic renal failure, they will be absolutely the same, regardless of what caused the development of the pathology.

Causes of development of chronic renal failure

It is believed that the disease in question most often occurs against the background of inflammatory and/or infectious kidney pathologies. But there are also diseases of other organs and systems that can also lead to chronic renal failure.

Doctors have identified a list of pathologies that contribute to the development of the disease in question:

• persistent high blood pressure - ;
• amyloidosis;

It is not at all necessary that when diagnosing the above diseases, the patient will experience chronic renal failure - this pathology is a complication and for its development several factors must come together.

Renal failure in the latent stage - symptoms

The clinical picture of renal failure in the latent stage will depend on what disease led to the development of the pathology. Symptoms can be very different - swelling that occurs during the day and is independent of the amount of fluid consumed, increased blood pressure for no apparent reason, pain concentrated in the lumbar region. Doctors often note that the first symptoms of chronic renal failure in the latent stage are completely ignored - this happens with progressive glomerulonephritis and/or polycystic kidney disease.

In the latent stage of the disease in question, the patient will complain of increased fatigue and decreased appetite, up to complete refusal of food. These complaints are absolutely not specific, therefore, the doctor will be able to make a correct diagnosis and associate such changes in the patient’s well-being with problems with kidney function only after a thorough examination of the patient.

Both the patient and the attending physician should be alerted during the night hours, which occur even with a minimal amount of fluid consumed in the evening. This condition may indicate that the kidneys are unable to concentrate urine.

In kidney diseases, some of the glomeruli die, and the remaining ones cannot cope with the function of this organ - the liquid is absolutely not absorbed in the tubules, the density of urine decreases so much that in some cases the indicators approach those of the blood plasma. To clarify this point, doctors prescribe the patient according to Zimnitsky - if a density of 1018 is not present in any portion of urine, then we can talk about the progression of renal failure. A urine density of 1010 is considered critical - this means that fluid reabsorption has completely stopped, and the disturbances in kidney function have gone too far.

The latent stage of development of chronic renal failure acquires more and more pronounced symptoms over time - for example, the patient begins to complain of increased thirst, but there is no high blood pressure (unless it was the cause of the development of the complication in question), a blood test does not show a decrease in the level of hemoglobin and electrolytes shifts. If a doctor examines a patient at this stage of development of the disease in question, a reduced amount of vitamin D and parathyroid hormone will be detected, although there will be no signs of progression of osteoporosis.

Note:at the latent stage of development of chronic renal failure, symptoms are reversible - with timely diagnosis and professional medical care, progression can be prevented.

Azotemic stage of renal failure - signs

If the latent stage of development of the disease in question was diagnosed in a timely manner, but treatment does not produce any results, then the progression of the pathology will occur at a rapid pace - the irreversible stage of chronic renal failure begins. In this case, the patient will complain about very specific symptoms:

1. Blood pressure rises, constant headaches occur and this is associated with a decrease in the synthesis of renin and renal prostaglandins in the kidneys.
2. Muscle mass becomes smaller, the patient loses weight sharply, intestinal upset appears, appetite decreases, and he is often worried - these symptoms are due to the fact that the intestines partially take over the function of removing toxins.
3. Erythropoietin in the kidneys begins to be produced in too small quantities, which leads to the development of persistent anemia.
4. There are complaints of numbness in the upper and lower extremities (feet and hands), corners of the mouth, pronounced muscle weakness - the cause of this condition is a lack of active calcium in the body and a decrease in calcium levels. For the same reason, the patient may experience disturbances in the psycho-emotional background - agitation or.

As chronic renal failure progresses, a more severe stage 4 of the disease occurs. It will have the following symptoms:

Manifestations of end-stage renal failure

At this stage of development of the disease in question, the patient receives only replacement treatment - he regularly undergoes hemodialysis and/or peritoneal dialysis.

The main signs of chronic renal failure in the terminal stage will be the following manifestations:

Note:The life of patients with chronic renal failure at stage 4 of development is not even calculated in days - in hours! Therefore, it is highly advisable to seek professional medical help much earlier, when the first symptoms of the disease in question appear.

Specific symptoms of chronic renal failure develop in later stages of pathology, when irreversible processes in the kidneys occur. And in order to identify the development of the disease in question at stages 1-2, you need to regularly take blood and urine tests - this is especially true for those patients who are at risk.

Tsygankova Yana Aleksandrovna, medical observer, therapist of the highest qualification category