Chronic renal failure (CRF): stages, symptoms, diagnosis and effective treatment. Basic functional indicators. Controlling fluid administration

Chronic renal failure- a symptom complex caused by a sharp decrease in the number and function of nephrons, which leads to disruption of the excretory and incretory functions of the kidneys, homeostasis, disorders of all types of metabolism, blood sugar, and the activity of all organs and systems.

For the correct selection of adequate treatment methods, it is extremely important to take into account the classification of chronic renal failure:

1. Conservative stage with a drop in glomerular filtration to 40-15 ml/min with great potential conservative treatment.
2. Terminal stage with glomerular filtration rate of about 15 ml/min, when extrarenal cleansing (hemodialysis, peritoneal dialysis) or kidney transplantation should be discussed.

1. Treatment of chronic renal failure in the conservative stage

Chronic renal failure, in the conservative stage, can still have positive influence and even reduce the severity of chronic renal failure. This especially applies to chronic pyelonephritis with initial or moderate symptoms of chronic renal failure. Stopping the exacerbation of the inflammatory process in the kidneys reduces the severity of renal failure.

1.2. Mode

The patient should avoid hypothermia, heavy physical and emotional stress. The patient needs optimal working and living conditions. He must be surrounded by attention and care, he must be given additional rest during work, and a longer vacation is also advisable.

1.3. Medical nutrition

The diet for chronic renal failure is based on the following principles:

• limiting dietary protein intake to 60-40-20 g per day, depending on the severity of renal failure;
• ensuring sufficient calorie content of the diet corresponding to the energy needs of the body, due to fats, carbohydrates, complete provision of the body with microelements and vitamins;
• limiting the intake of phosphates from food;
• control over the intake of sodium chloride, water and potassium.

The implementation of these principles, especially the restriction of protein and phosphates in the diet, reduces the additional load on functioning nephrons, contributes to a longer preservation of satisfactory renal function, reduces azotemia, and slows down the progression of chronic renal failure. Limiting protein in food reduces the formation and retention of nitrogenous waste in the body, reduces the content of nitrogenous waste in the blood serum due to a decrease in the formation of urea (with the breakdown of 100 g of protein, 30 g of urea is formed) and due to its reutilization.

On early stages CRF with a blood creatinine level of up to 0.35 mmol/l and urea up to 16.7 mmol/l (glomerular filtration about 40 ml/min), a moderate protein restriction to 0.8-1 g/kg is recommended, i.e. up to 50-60 g per day. At the same time, 40 g should be high-value protein in the form of meat, poultry, eggs, and milk. It is not recommended to overuse milk and fish due to their high phosphate content.

When serum creatinine levels are from 0.35 to 0.53 mmol/l and urea levels are 16.7-20.0 mmol/l (glomerular filtration rate is about 20-30 ml/min), protein should be limited to 40 g per day (0.5-0.6 g/kg). At the same time, 30 g should be high-value protein, and bread, cereals, potatoes and other vegetables should account for only 10 g of protein per day. 30-40 g of complete protein per day is minimal amount protein, which is required to maintain a positive nitrogen balance. If a patient with chronic renal failure has significant proteinuria, the protein content in food is increased according to the loss of protein in the urine, adding one egg (5-6 g of protein) for every 6 g of urine protein.

In general, the patient’s menu is compiled within table No. 7. The patient’s daily diet includes the following products: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina porridge, rice, buckwheat, pearl barley. Particularly suitable due to their low protein content and at the same time high energy value are potato dishes (pancakes, cutlets, babkas, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put

2-3 tablespoons of sugar per glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and, in doses, proteins. Calculating the daily amount of protein in the diet is mandatory. When compiling a menu, you should use tables reflecting the protein content in the product and its energy value (Table 41).

An approximate version of diet No. 7 for 40 g of protein per day:

Breakfast

• Soft-boiled egg
• Rice porridge - 60 g
• Honey - 50 g

Dinner

• Fresh cabbage soup - 300 g
• Fried fish with mashed potatoes - 150 g
• Apples

Dinner

• Mashed potatoes - 300 g
• Vegetable salad - 200 g
• Milk - 200 g

The potato and potato-egg diets have become widespread in the treatment of patients with chronic renal failure. These diets are high in calories due to protein-free foods - carbohydrates and fats. High calorie food reduces catabolism and reduces the breakdown of your own protein. Honey, sweet fruits (poor in protein and potassium), can also be recommended as high-calorie foods. vegetable oil, lard (in the absence of edema and hypertension). There is no need to prohibit alcohol in chronic renal failure (with the exception of alcoholic nephritis, where abstinence from alcohol can lead to improved kidney function).

1.4. Correction of water balance disorders

If the level of creatinine in the blood plasma is 0.35-1.3 mmol/l, which corresponds to a glomerular filtration rate of 10-40 ml/min, and there are no signs of heart failure, then the patient should take enough fluid to maintain diuresis within 2-2.5 l per day. day. In practice, we can assume that under the above conditions there is no need to limit fluid intake. This water regime makes it possible to prevent dehydration and at the same time release an adequate amount of fluid due to osmotic diuresis in the remaining nephrons. In addition, high diuresis reduces the reabsorption of waste in the tubules, promoting their maximum excretion. Increased fluid flow in the glomeruli increases glomerular filtration. When the glomerular filtration rate is more than 15 ml/min, the risk of fluid overload during oral administration is minimal.

In some cases, with the compensated stage of chronic renal failure, symptoms of dehydration may appear due to compensatory polyuria, as well as vomiting and diarrhea. Dehydration can be cellular (excruciating thirst, weakness, drowsiness, reduced skin turgor, sunken face, very dry tongue, increased blood viscosity and hematocrit, possibly increased body temperature) and extracellular (thirst, asthenia, dry sagging skin, sunken face, arterial hypotension , tachycardia). With the development of cellular dehydration, intravenous administration of 3-5 ml of 5% glucose solution per day under the control of central venous pressure is recommended. For extracellular dehydration, an isotonic sodium chloride solution is administered intravenously.

1.5. Correction of electrolyte imbalances

Reception table salt patients with chronic renal failure without edema syndrome and arterial hypertension should not be restricted. Sharp and prolonged salt restriction leads to dehydration of patients, hypovolemia and deterioration of kidney function, increasing weakness, and loss of appetite. The recommended amount of salt in the conservative phase of chronic renal failure in the absence of edema and arterial hypertension is 10-15 g per day. With the development of edema syndrome and severe arterial hypertension, the consumption of table salt should be limited. Patients with chronic glomerulonephritis with chronic renal failure are allowed 3-5 g of salt per day, with chronic pyelonephritis with chronic renal failure - 5-10 g per day (in the presence of polyuria and the so-called salt-losing kidney). It is advisable to determine the amount of sodium excreted in the urine per day in order to calculate the required amount of table salt in the diet.

In the polyuric phase of chronic renal failure, pronounced losses of sodium and potassium in the urine may occur, which leads to the development hyponatremia And hypokalemia.

In order to accurately calculate the amount of sodium chloride (in g) a patient needs per day, you can use the formula: amount of sodium excreted in urine per day (in g) x 2.54. Practically, 5-6 g of table salt per 1 liter of urine excreted is added to the patient’s food. The amount of potassium chloride required by a patient per day to prevent the development of hypokalemia in the polyuric phase of chronic renal failure can be calculated using the formula: the amount of potassium excreted in the urine per day (in g) x 1.91. When hypokalemia develops, the patient is given vegetables and fruits rich in potassium (Table 43), as well as potassium chloride orally in the form of a 10% solution, based on the fact that 1 g of potassium chloride (i.e. 10 ml of a 10% solution of potassium chloride) contains 13.4 mmol potassium or 524 mg potassium (1 mmol potassium = 39.1 mg).

With moderate hyperkalemia(6-6.5 mmol/l) you should limit foods rich in potassium in your diet, avoid prescribing potassium-sparing diuretics, take ion exchange resins (resonium 10 g 3 times a day per 100 ml of water).

For hyperkalemia of 6.5-7 mmol/l, it is advisable to add intravenous glucose with insulin (8 units of insulin per 500 ml of 5% glucose solution).

With hyperkalemia above 7 mmol/l there is a risk of cardiac complications (extrasystole, atrioventricular block, asystole). In this case, in addition to intravenous administration of glucose with insulin, intravenous administration of 20-30 ml of 10% calcium gluconate solution or 200 ml of 5% sodium bicarbonate solution is indicated.

For measures to normalize calcium metabolism, see the section “Treatment of uremic osteodystrophy.”

1.6. Reducing the retention of end products of protein metabolism (combat azotemia)

7.6.7. Diet

For chronic renal failure, a low protein diet is used (see above).

7.6.2. Sorbents

Sorbents used along with the diet adsorb ammonia and other toxic substances in the intestines.

The most commonly used sorbents are enterodesyl carbolene, 5 g per 100 ml of water, 3 times a day, 2 hours after meals. Enterodesis- a drug of low molecular weight polyvinylpyrrolidone, has detoxification properties, binds toxins entering the gastrointestinal tract or formed in the body, and removes them through the intestines. Sometimes oxidized starch in combination with coal is used as sorbents.

Widely used in chronic renal failure enterosorbents - different kinds activated carbon for oral administration. You can use enterosorbents of the IGI, SKNP-1, SKNP-2 brands at a dose of 6 g per day. In the Republic of Belarus, enterosorbent Belosorb-P is produced, which is used 1-2 g 3 times a day. The addition of sorbents increases the excretion of nitrogen in feces and leads to a decrease in the concentration of urea in the blood serum.

7.6.3. Colon lavage, intestinal dialysis

With uremia, up to 70 g of urea, 2.9 g of creatinine, 2 g of phosphates and 2.5 g of uric acid. By removing these substances from the intestines, intoxication can be reduced, so intestinal lavage, intestinal dialysis, and siphon enemas are used to treat chronic renal failure. Intestinal dialysis is the most effective. It is performed using a two-channel probe up to 2 m long. One channel of the probe is designed to inflate a balloon, with which the probe is fixed in the intestinal lumen. The probe is inserted under X-ray control into the jejunum, where it is fixed with a balloon. Through another channel the probe is inserted into small intestine over 2 hours in equal portions of 8.-10 l of hypertonic solution of the following composition: sucrose - 90 g/l, glucose - 8 g/l, potassium chloride - 0.2 g/l, sodium bicarbonate - 1 g/l, sodium chloride - 1 g/l. Intestinal dialysis is effective for moderate symptoms of uremic intoxication.

In order to develop a laxative effect and thereby reduce intoxication, they are used sorbitol And xylitol. When they are administered orally in a dose of 50 g, severe diarrhea develops with the loss of a significant amount of liquid (3-5 liters per day) and nitrogenous waste.

If hemodialysis is not possible, the method of controlled forced diarrhea is used using hyperosmolar Young's solution of the following composition: mannitol - 32.8 g/l, sodium chloride - 2.4 g/l, potassium chloride - 0.3 g/l, calcium chloride - 0.11 g/l, sodium bicarbonate “1.7 g/l. Within 3 hours you should drink 7 liters of warm solution (1 glass every 5 minutes). Diarrhea begins 45 minutes after starting to take Young's solution and ends 25 minutes after stopping taking it. The solution is taken 2-3 times a week. It tastes good. Mannitol can be replaced with sorbitol. After each procedure, urea in the blood decreases by 37.6%, potassium by 0.7 mmol/l, the level of bicarbonates increases, and creatinine does not change. The duration of treatment is from 1.5 to 16 months.

1.6.4. Gastric lavage (dialysis)

It is known that with a decrease in the nitrogen excretory function of the kidneys, urea and other products of nitrogen metabolism begin to be released by the gastric mucosa. In this regard, gastric lavage can reduce azotemia. Before gastric lavage, the level of urea in the gastric contents is determined. If the level of urea in the gastric contents less than level in the blood by 10 mmol/l or more, the excretory capabilities of the stomach are not exhausted. 1 liter of 2% sodium bicarbonate solution is injected into the stomach, then sucked off. Washing is done in the morning and evening. In 1 session you can remove 3-4 g of urea.

1.6.5. Antiazotemic agents

Antiazotemic agents have the ability to increase the secretion of urea. Despite the fact that many authors consider their anti-azotemic effect to be problematic or very weak, these drugs have gained great popularity among patients with chronic renal failure. In the absence of individual intolerance, they can be prescribed in the conservative stage of chronic renal failure.

Hofitol - purified extract of the cinara scolymus plant, available in ampoules of 5-10 ml (0.1 g of pure substance) for intravenous and intramuscular injection, course of treatment - 12 injections.

Lespenefril - obtained from the stems and leaves of the legume plant Lespedesa capitata, available in the form of an alcohol tincture or lyophilized extract for injection. It is used orally at 1-2 teaspoons per day, in more severe cases - from 2-3 to 6 teaspoons per day. For maintenance therapy, 1/2 -1 teaspoon is prescribed for a long time every other day. Lespenefril is also available in ampoules in the form of lyophilized powder. Administered intravenously or intramuscularly (an average of 4 ampoules per day). It is also administered intravenously in an isotonic sodium chloride solution.

1.6.6. Anabolic drugs

Anabolic drugs are used to reduce azotemia in the initial stages of chronic renal failure; when treated with these drugs, urea nitrogen is used for protein synthesis. Retabolil 1 ml intramuscularly is recommended once a week for 2-3 weeks.

1.6.7. Parenteral administration of detoxification agents

Hemodez, 5% glucose solution, etc. are used.

1.7. Correction of acidosis

Bright clinical manifestations acidosis usually does not. The need for its correction is due to the fact that with acidosis, bone changes may develop due to the constant retention of hydrogen ions; in addition, acidosis contributes to the development of hyperkalemia.

In mild acidosis, restricting dietary protein leads to an increase in pH. In mild cases, to relieve acidosis, you can use soda (sodium bicarbonate) orally in a daily dose of 3-9 g or sodium lactate 3-6 g per day. Sodium lactate is contraindicated in cases of liver dysfunction, heart failure and other conditions accompanied by the formation of lactic acid. In mild cases of acidosis, you can also use sodium citrate orally in a daily dose of 4-8 g. In case of severe acidosis, sodium bicarbonate is administered intravenously in the form of a 4.2% solution. The amount of 4.2% solution required to correct acidosis can be calculated as follows: 0.6 x BE x body weight (kg), where BE is the deficiency of buffer bases (mmol/l). If it is not possible to determine the shift of buffer bases and calculate their deficiency, you can administer a 4.2% soda solution in an amount of about 4 ml/kg. I. E. Tareeva draws attention to the fact that intravenous administration of a soda solution in an amount of more than 150 ml requires special caution due to the risk of depression of cardiac activity and the development of heart failure.

When using sodium bicarbonate, acidosis is reduced and, as a result, the amount of ionized calcium also decreases, which can lead to seizures. In this regard, intravenous administration of 10 ml of 10% calcium gluconate solution is advisable.

Trisamine is often used to treat severe acidosis. Its advantage is that it penetrates the cell and corrects intracellular pH. However, many consider the use of trisamine contraindicated in cases of impaired renal excretory function; in these cases, severe hyperkalemia is possible. Therefore, trisamine has not received widespread use as a means to relieve acidosis in chronic renal failure.

Relative contraindications to alkali infusions are: edema, heart failure, high arterial hypertension, hypernatremia. For hypernatremia, the combined use of soda and 5% glucose solution in a ratio of 1:3 or 1:2 is recommended.

1.8. Treatment of arterial hypertension

It is necessary to strive to optimize blood pressure, since hypertension sharply worsens the prognosis and reduces the life expectancy of patients with chronic renal failure. Blood pressure should be kept within 130-150/80-90 mmHg. Art. In most patients with a conservative stage of chronic renal failure, arterial hypertension is moderately expressed, i.e. systolic blood pressure ranges from 140 to 170 mm Hg. Art., and diastolic - from 90 to 100-115 mm Hg. Art. Malignant arterial hypertension in chronic renal failure is observed infrequently. The reduction in blood pressure should be carried out under the control of diuresis and glomerular filtration. If these indicators decrease significantly with a decrease in blood pressure, the dose of drugs should be reduced.

Treatment of patients with chronic renal failure with arterial hypertension includes:

1. Restriction in the diet of table salt to 3-5 g per day, with severe arterial hypertension - to 1-2 g per day, and as soon as blood pressure normalizes, salt intake should be increased.
2. Prescription of natriuretics - furosemide at a dose of 80-140-160 mg per day, uregit (ethacrynic acid) up to 100 mg per day.
   Both drugs slightly increase glomerular filtration. These drugs are used in tablets, and for pulmonary edema and other urgent conditions - intravenously. In large doses, these drugs can cause hearing loss and increase the toxic effect of cephalosporins. In case of insufficient effectiveness hypotensive effect of these diuretics, any of them can be combined with hypothiazide (25-50 mg orally in the morning). However, hypothiazide should be used at creatinine levels up to 0.25 mmol/l; at higher creatinine levels, hypothiazide is ineffective, and the risk of hyperuricemia increases.
3. Prescription of antihypertensive drugs with predominantly central adrenergic action - dopegit and clonidine. Dopegite is converted into alphamethylnorepinephrine in the central nervous system and causes a decrease in blood pressure by enhancing the depressant effects of the vapor of the ventricular nucleus of the hypothalamus and stimulating the postsynaptic α-adrenergic receptors of the medulla oblongata, which leads to a decrease in the tone of the vasomotor centers. Dopegit can be used in a dose of 0.25 g 3-4 times a day, the drug increases glomerular filtration, but its elimination in chronic renal failure is significantly slowed down and its metabolites can accumulate in the body, causing a number of side effects, in particular, depression of the central nervous system and a decrease in myocardial contractility , therefore the daily dose should not exceed 1.5 g. Clonidine stimulates α-adrenergic receptors of the central nervous system, which leads to inhibition of sympathetic impulses from the vasomotor center to the medullary substance and medulla, which causes a decrease in blood pressure. The drug also reduces the content of renin in the blood plasma. Clonidine is prescribed at a dose of 0.075 g 3 times a day; if the hypotensive effect is insufficient, the dose is increased to 0.15 mg 3 times a day. It is advisable to combine dopegit or clonidine with saluretics - furosemide, hypothiazide, which allows you to reduce the dose of clonidine or dopegit and reduce the side effects of these drugs.
4. In some cases, it is possible to use β-blockers ( anaprilina, obsidan, inderala). These drugs reduce the secretion of renin, their pharmacokinetics in chronic renal failure are not affected, therefore I. E. Tareeva allows their use in large daily doses - up to 360-480 mg. However, such large doses are not always required. It is better to take smaller doses (120-240 mg per day) to avoid side effects. The therapeutic effect of the drugs is enhanced when they are combined with saluretics. When combining arterial hypertension with heart failure when treating with p-blockers, caution should be exercised.
5. In the absence of a hypotensive effect from the above measures, it is advisable to use peripheral vasodilators, since these drugs have a pronounced hypotensive effect and increase renal blood flow and glomerular filtration. It is used prazosin (minipress) 0.5 mg 2-3 times a day. ACE inhibitors are especially indicated - capoten (captopril) 0.25-0.5 mg/kg 2 times a day. The advantage of capote and its analogues is their normalizing effect on intraglomerular hemodynamics.

For arterial hypertension refractory to treatment, ACE inhibitors are prescribed in combination with saluretics and β-blockers. Doses of drugs are reduced as chronic renal failure progresses, the glomerular filtration rate and the level of azotemia are constantly monitored (if the renovascular mechanism of arterial hypertension predominates, filtration pressure and glomerular filtration rate decrease).

To relieve a hypertensive crisis in chronic renal failure, furosemide or verapamil is administered intravenously, captopril, nifedipine or clonidine are used sublingually. drug therapy extracorporeal methods for removing excess sodium are used: isolated blood ultrafiltration, hemodialysis (I.M. Kutyrina, N.L. Livshits, 1995).

Often, a greater effect of antihypertensive therapy can be achieved not by increasing the dose of one drug, but by a combination of two or three drugs acting on various pathogenetic links of hypertension, for example, a saluretic and a sympatholytic, a β-blocker and a saluretic, a drug central action and saluretika, etc.

1.9. Treatment of anemia

Unfortunately, treatment of anemia in patients with chronic renal failure is not always effective. It should be noted that most patients with chronic renal failure tolerate anemia satisfactorily with a decrease in hemoglobin levels even to 50-60 g/l, as adaptive reactions develop that improve the oxygen transport function of the blood. The main directions of treatment of anemia in chronic renal failure are as follows.

1.9.1. Less iron preirates

Iron supplements are usually taken orally and only if poorly tolerated and gastrointestinal disorders they are administered intravenously or intramuscularly. Ferroplex is most often prescribed, 2 tablets 3 times a day after meals; ferroceron 2 tablets 3 times a day; Conferon 2 tablets 3 times a day; ferro-gradument, tardiferon (extended-release iron preparations) 1-2 tablets 1-2 times a day (Table 44).

Iron supplements should be dosed based on the fact that the minimum effective daily dose of ferrous iron for an adult is 100 mg, and the maximum appropriate daily dose is 300-400 mg. Therefore, it is necessary to begin treatment with minimal doses, then gradually, if the drugs are well tolerated, the dose is increased to the maximum appropriate. The daily dose is taken in 3-4 doses, and extended-release drugs are taken 1-2 times a day. Iron supplements are taken 1 hour before meals or no earlier than 2 hours after meals. Total duration of treatment oral medications is at least 2-3 months, and often up to 4-6 months, which is required to fill the depot. After reaching a hemoglobin level of 120 g/l, taking the drugs continues for at least 1.5-2 months, in the future it is possible to switch to maintenance doses. However, it is, of course, usually not possible to normalize hemoglobin levels due to the irreversibility of the pathological process underlying chronic renal failure.

1.9.2. Androgen treatment

Androgens activate erythropoiesis. They are prescribed to men in relatively large doses - testosterone intramuscularly at 400-600 mg of a 5% solution once a week; Sustanon, testenate intramuscularly 100-150 mg of 10% solution 3 times a week.

1.9.3. Treatment with Recormon

Recombinant erythropoietin - Recormon is used to treat erythropoietin deficiency in patients with chronic renal failure. One ampoule of the drug for injection contains 1000 ME. The drug is administered only subcutaneously, the initial dose is 20 IU/kg 3 times a week, then, if there is no effect, the number of injections is increased by 3 every month. The maximum dose is 720 units/kg per week. After an increase in hematocrit by 30-35%, a maintenance dose is prescribed, which is equal to half the dose at which the increase in hematocrit occurred, the drug is administered at 1-2 week intervals.

Side effects Recormon: increased blood pressure (in case of severe arterial hypertension, the drug is not used), increased platelet count, the appearance of a flu-like syndrome at the beginning of treatment (headache, joint pain, dizziness, weakness).

Treatment with erythropoietin is currently the most effective method of treating anemia in patients with chronic renal failure. It has also been established that treatment with erythropoietin has a positive effect on the function of many endocrine organs (F. Kokot, 1991): renin activity is suppressed, the level of aldosterone in the blood decreases, the level of atrial natriuretic factor in the blood increases, and the levels of growth hormone, cortisol, prolactin, ACTH also decrease , pancreatic polypeptide, glucagon, gastrin, the secretion of testosterone increases, which, along with a decrease in prolactin, has a positive effect on the sexual function of men.

1.9.4. Red blood cell transfusion

Transfusion of red blood cells is performed in cases of severe anemia (hemoglobin level below 50-45 g/l).

1.9.5. Multivitaminothertia

It is advisable to use balanced multivitamin complexes (undevit, oligovit, duovit, dekamevit, fortevit, etc.).

1.10. Treatment of uremic osteostrophy

1.10.1. Maintaining close to normal levels of calcium and phosphorus in the blood

It is also necessary to reduce the intake of phosphates from food (they are found mainly in protein-rich foods) and prescribe drugs that reduce the absorption of phosphates in the intestine. It is recommended to take a™agel 10 ml 4 times a day; it contains aluminum hydroxide, which forms insoluble compounds with phosphorus that are not absorbed in the intestines.

1.10.2. Suppression of parathyroid gland hyperactivity

This principle of treatment is carried out by taking calcium orally (according to the principle feedback this inhibits the function of the parathyroid glands), as well as taking vitamin D preparations - an oil or alcohol solution of vitamin D (ergocalciferol) in a daily dose of 100,000 to 300,000 IU; Vitamin D 3 (oxidevit) is more effective, which is prescribed in capsules at 0.5-1 mcg per day.

Vitamin D preparations significantly enhance the absorption of calcium in the intestine and increase its level in the blood, which inhibits the function of the parathyroid glands.

Tachistine has a similar effect to vitamin D, but has a more energetic effect - 10-20 drops of a 0.1% oil solution 3 times a day orally.

As the level of calcium in the blood increases, the dosage of the drugs is gradually reduced.

For advanced uremic osteodystrophy, subtotal parathyroidectomy may be recommended.

1.10.3. Treatment with osteoquin

In recent years, the drug osteoquin (ipriflavone) has appeared for the treatment of osteoporosis of any origin. The proposed mechanism of its action is inhibition of bone resorption by enhancing the action of endogenous calcitonin and improving mineralization due to calcium retention. The drug is prescribed at a dose of 0.2 g 3 times a day for an average of 8-9 months.

1.11. Treatment of infectious complications

The appearance of infectious complications in patients with chronic renal failure leads to sharp decline kidney function. If there is a sudden drop in glomerular filtration rate in a nephrology patient, the possibility of infection must first be excluded. When carrying out antibacterial therapy, one should remember the need to reduce doses of drugs, taking into account the impairment of renal excretory function, as well as the nephrotoxicity of a number of antibacterial agents. The most nephrotoxic antibiotics are aminoglycosides (gentamicin, kanamycin, streptomycin, tobramycin, brulamycin). The combination of these antibiotics with diuretics increases the possibility of toxic effects. Tetracyclines are moderately nephrotoxic.

Are not nephrotoxic the following antibiotics: chloramphenicol, macrolides (erythromycin, oleandomycin), oxacillin, methicillin, penicillin and other drugs of the penicillin group. These antibiotics can be prescribed in normal doses. For infection urinary tract preference is also given to cephalosporins and penicillins, secreted by tubules, which ensures their sufficient concentration even with a decrease in glomerular filtration (Table 45).

Nitrofuran compounds and nalidixic acid preparations can be prescribed for chronic renal failure only in the latent and compensated stages.

Note: in case of significant impairment of renal function, the use of aminoglycosides (gentamicin, kanamycin, streptomycin) is not recommended.

auno.kz

Diet 7 for kidney failure

When choosing a diet in case of renal failure, you can create a diet individually for an individual patient. But at the same time, you can use existing schemes. The most common in use are dietary tables developed by Pevzner. Among them, for renal failure, dietary table No. 7 is recommended. This table is designed for patients with kidney problems. At the same time, diet No. 7 also contains a more detailed division depending on the stage and type of kidney disease. So there are dietary tables No. 7a, 7b, 7c, 7d and 7p.

Dietary table No. 7 is prescribed to a patient with acute glomerulonephritis, who is at the recovery stage, or with chronic subsiding glomerulonephritis. This diet is also indicated for nephropathy in pregnant women.

This diet allows you to facilitate the process of removing under-oxidized metabolic products and nitrogenous waste from the body, create a gentle regime for the kidneys and reduce arterial hypertension.

Of all the seventh group diets, this one is the richest in protein. Up to 80 g of protein is allowed, half of which can be of animal origin, 90 g of fat, about 450 g of carbohydrates, free liquid - 1 liter. Salt The amount of salt is limited to 6 g. The diet is quite high-calorie - 2750 - 3150 kcal per day, which allows you to save active work all systems of the body.

Products should be cooked boiled, although frying after cooking is allowed. The food is crushed. Substances that irritate the cardiovascular and central nervous systems are not allowed.

Diet for chronic renal failure

In case of chronic renal failure, the diet is selected depending on the patient’s condition, the stage of development of the failure, and the duration of the last period of exacerbation. Most often, standard regimens are chosen, which can then be adjusted depending on the needs of a particular patient.

But usually, in case of chronic renal failure, diet table No. 7 or 7a is chosen. Also, in some cases, diets No. 7, 7a, 7b are combined, using them alternately. Dietary table No. 7a is prescribed in case of exacerbation of chronic processes of renal failure. This diet is prescribed only for short periods of about a week. If chronic renal failure is in remission after an exacerbation, then diet No. 7b with a gradual transition to diet No. 7 would be more appropriate.

In any case, all dietary regimens for chronic renal failure are aimed at reducing protein consumption to one degree or another to reduce azotemia, be gentle on the kidneys, and also maintain such a balance of protein in food so that, while reducing the load on the kidneys, the destruction of the proteins of the body itself is prevented .

Diet No. 7a is the most limited in protein composition, only 20 g of protein, 80 g of fat, 350 g of carbohydrates are allowed. Salt is limited to 2 g. The volume of liquid consumed, as with diet 7b, should be 200 - 300 ml more than the volume of urine excreted. The energy value of the diet is 2200 kcal. Food is boiled, fried, baked. Salt is strictly limited.

Diet for acute renal failure

In case of acute renal failure, diet No. 7b is most suitable. Although in this condition, especially in the initial stages, the patient may refuse to eat food due to nausea, vomiting, and distortion of tastes, this is unacceptable because it can accelerate the breakdown of the body’s own proteins.

This diet is also designed to create a gentle regime for kidney function, reduce blood pressure, improve urination and blood circulation, and promote the removal of nitrogenous waste and other metabolic products from the body.

The amount of protein, salt and liquid in the diet is sharply limited. Proteins are 30–40 g, fats 80–90 g, carbohydrates 400–500 g. Salt is reduced to 2–3 g per day. The amount of daily fluid is calculated depending on how much urine the patient excretes per day. Thus, the amount of liquid consumed should be one glass greater than that excreted.

The calorie content of food is approximately 2700 - 3000 kcal per day. Food is prepared without adding salt, salt is added to taste on the plate within the permitted volumes. Products can be boiled or baked.

Diet menu for kidney failure

When creating a menu for patients suffering from renal failure and using one or another diet, an individual approach is always needed, calculating the amount of protein, balancing the diet, and observing the energy value of the products.

But in any case, we can identify general trends and a list acceptable products, which is not so limited in its diversity.

So, the diet menu for kidney failure may include salt-free yeast pancakes, salt-free bread, egg dishes, but in very limited quantities, whole milk, sour cream, cream, yogurt. Both vegetable and animal fats are allowed, as well as all possible types cereals with any method of preparation. Allowed fresh vegetables, with the exception of those that contain a strong taste or are hard on the kidneys, such as mushrooms, radishes, spinach. Vegetables and cereals can be served in the form of various soups with dressings made from fried onions, sour cream, and herbs. also in full volume Various fruits and berries are allowed. They can be prepared in the form of compotes, soups, jelly, jelly, jam. You can also consume honey and candies that do not contain chocolate. It is allowed to drink all kinds of juices, decoctions (for example, rosehip decoction), tea, but not strong tea. Drinks such as coffee, cocoa, mineral water, artificially colored or very caustic drinks are completely excluded. It is recommended to use cinnamon, vanilla, and citric acid as possible seasonings and spices. You can use white (milk) or tomato sauce, vegetable and fruit gravy. But it is necessary to completely exclude such spicy seasonings like horseradish, pepper, mustard.

Diet recipes for kidney failure

Vegetarian borscht

• Beetroot 1 piece
• Potatoes 2 pcs
• Onion 1 piece
• Carrot 1 piece
• White cabbage 300 g
• Tomato 1 piece
• Water 1.5 l
• Sugar 0.5 g
• Sour cream, herbs for dressing to taste
• Add salt to the finished dish within the limits.

Wash the beets, peel them and place in boiling water. Cook until half cooked. After that, remove the beets from the broth, let cool and grate on a coarse grater.

Peel the onion, carrot and tomato, chop finely and simmer in oil.

Place peeled and diced potatoes into the boiling beet broth, and 10 minutes later add cabbage. When the cabbage is cooked, add the stewed carrots, onions and tomatoes. Bring to a boil, add sugar. Before serving, season the borscht with sour cream and herbs, and add some salt.

Carrot cutlets

• Carrots 500 g
• Semolina 100 g
• Sugar 1 tbsp. l.
• Salt to taste within limits
• Sour cream and herbs for dressing to taste

Boil the carrots, cool, peel and grate on a fine grater. Then add 50 g of semolina, mix well, add sugar, add salt if desired. Form cutlets from the resulting mass and roll them in the remaining semolina. Fry in vegetable oil for 3 minutes on one side, then turn over to the other, reduce the heat, cover and fry for another 10 minutes. Serve with sour cream and herbs dressing.

When choosing a diet for renal failure, you should base it not only on the diagnosis itself, but also on the degree of renal failure, acute or chronic stage of the disease, calculation of the concentration of proteins in the food itself and at the same time the content of protein metabolism products in the blood, general electrolyte balance, the presence of concomitant diseases in the patient.

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Beetroot

Ingredients: beet broth – 500 ml, beets – 1 pc., fresh cucumber – 1 pc., potatoes – 2 pcs., egg – 1 pc., green onion, herbs, sour cream, citric acid.

Boil the peeled beets (can be cut into several parts), cool the broth. Chop green onions, dill, parsley, beets, cucumbers, boiled potatoes. Season with sour cream and citric acid.

Fruit okroshka

Ingredients: fruit infusion – 500 ml, apple – 1 pc., melon – 100 g, peaches – 5 pcs., cherries 1 glass, lettuce, sour cream.

Peel the apple, melon, cut them into cubes. Scald and peel the peaches and chop the pulp. Wash the cherries and remove the pits. Tear the salad with your hands. Grind cherries, fruit peels, pour boiling water and leave for 1.5–2 hours. Pour the infusion over the cooked fruits. Serve with sour cream.

Peppers stuffed with carrots

Ingredients: peppers – 4 pcs., carrots – 3 pcs., onions – 3 pcs., tomatoes – 3 pcs., vegetable oil – 3 tbsp. l., bay leaf, parsley and dill.

Remove the seeds from the peppers, rinse and stuff with carrots, previously stewed with onions. Place the prepared peppers in a saucepan, add water, add chopped tomatoes, bay leaves and simmer until tender.

Stuffed zucchini

Ingredients: zucchini – 1 medium, for minced meat: boiled rice – 1 glass, egg – 1 pc., carrots – 1 pc.... onion – 1 pc., sour cream – 100 ml.

Cut the zucchini into thick slices, remove the core and peel. Prepare minced meat from a mixture of rice, boiled and then fried onions, carrots and eggs and fill the zucchini, place on a baking sheet, pour in sour cream. Bake in the oven until done.

Pumpkin stewed with dill

Ingredients: pumpkin – 1 medium, onion – 3 pcs., dill, sour cream, lemon juice.

Pour water (2 cups) into sliced ​​peeled pumpkin along with finely chopped onions and simmer over low heat until smooth. 5 minutes before readiness, add chopped dill. Before serving, top with sour cream. You can add lemon juice.

Soaked carrot pudding

Ingredients: carrots – 2 pcs., butter – 15 g, sour cream – 2 tbsp. l., milk – 50 ml, cottage cheese 50 g, egg – 1 pc., sugar to taste.

Grate the peeled carrots on a fine grater, pour in 2 liters of cold water and soak for 3-4 hours, changing the water every hour. Then squeeze the carrots through cheesecloth, pour in milk, add 2/3 of the oil and simmer. Add the yolk mixed with grated cottage cheese, as well as whipped egg white and sugar to the prepared carrots, mix everything, put it in a greased mold and bake. Serve with sour cream.

Beetroot with apples

Beets – 5 pcs., apple – 2 pcs., sour cream 100 ml, citric acid to taste.

Peel the young beets and grate them on a coarse grater. Then put it in a saucepan, pour in a small amount hot water and simmer until half cooked over low heat. Add grated apples, sour cream and simmer until done. At the end add citric acid. Boil.

Eggplant baked with curdled milk

Ingredients: eggplants – 4 pcs., tomatoes – 5-6 pcs., egg – 2 pcs., curdled milk – 1 glass, butter – 50 g.

Wash the eggplants, cut crosswise into slices 1 cm thick, add salt, leave for 10–15 minutes, then rinse in cold water, pat dry with a napkin and fry in oil on both sides. Place the eggplants in a deep frying pan, layering them with sliced ​​tomatoes. Beat eggs with curdled milk, pour mixture over eggplants and bake.

Boiled meat and cottage cheese cutlets

Ingredients: beef – 200 g, egg – 1 pc., cottage cheese – 100 g, butter.

Boil the meat until almost fully cooked. Pass through a meat grinder 2 times along with cottage cheese. Add the egg, beat and cut into cutlets. Bake them in the oven. Serve with a vegetable side dish.

Steamed boiled chicken cutlets

Ingredients: chicken fillet – 200 g, potatoes – 1 pc., milk – 50 ml, butter – 30 g, egg – 1 pc.

Pass the pulp of the boiled chicken through a meat grinder, mix with grated potatoes (the juice from the potato mass can be squeezed out if there is a lot of it). Add oil and mix well. Form cutlets and bake in the oven.

Stuffed cabbage rolls with minced chicken

Ingredients: white cabbage – 800 g, chicken fillet – 300 g, tomatoes – 5 pcs., sour cream 2 tbsp. l., vegetable oil - 100 ml, rice 150 g.

Pass the boiled chicken fillet through a meat grinder. Boil the rice, cool and mix with minced chicken. Remove the cabbage leaves from the head, cook them in boiling water for 3–5 minutes, remove from the water, and cool. Place minced meat on each cabbage leaf and wrap it in the form of sausages or envelopes. Place in a saucepan, add broth from cabbage leaves, add chopped tomatoes and simmer for 30–40 minutes. Serve with sour cream.

Tomatoes stuffed with meat

Ingredients: tomatoes - 2 pcs., veal - 100 g, egg - 1 pc., green onions, dill, green pepper, sour cream - 50 g, mayonnaise - 2 tbsp. l.

Chop the white of a hard-boiled egg, and finely chop the green onions and peppers. Cut the boiled veal into small cubes and mix with chopped products, herbs and half of the sauce made from mayonnaise mixed with sour cream. After this, cut off the tops of the tomatoes, remove the cores, chop finely and add to the minced meat, which is used to fill the tomatoes.

Before serving, pour the remaining sauce over the tomatoes and sprinkle with chopped herbs.

Zucchini with meat

Ingredients: zucchini – 500 g, boiled chicken breast – 150 g, rice – 70 g, tomatoes – 2 pcs., onions – 2 pcs., sour cream – 70 g, vegetable oil, dill.

Peel the zucchini and cut into rings 1.5–2 cm thick. Make a depression in the middle and add minced meat made from chicken breast, mixed with boiled rice. Place on a baking sheet, having previously greased it with vegetable oil. For the sauce, simmer the tomatoes and onions, add sour cream. Pour this sauce over the zucchini and bake in the oven.

Meat casserole

Ingredients: potatoes – 5 pcs., meat – 300 g, onions – 2 pcs., egg – 2 pcs., milk – 150 ml, parsley and dill.

Boil the potatoes, mash them, add a little potato broth and eggs. Boil the meat, pass through a meat grinder and mix with boiled and then fried onions. Place a layer of potatoes on a baking sheet greased with vegetable oil, and minced meat on it. Pour in eggs beaten with milk and bake in the oven for 10 minutes at +200 °C. Sprinkle with herbs before serving.

Fish stewed with milk and carrots

Compound: fish fillet– 800 g, carrots – 2 pcs., onions – 2 pcs., milk – 500 ml.

Boil the fish fillet until almost done, cut into portions, place in a deep frying pan, add boiled and then fried onion in vegetable oil and carrots cut into round slices. Pour milk, simmer covered for 15 minutes.

Cod stewed in vegetables

Ingredients: cod – 200 g, carrots – 1 pc., onion – 1 pc., tomato – 1 pc., sour cream – 2 tbsp. l., water – 100 ml.

Boil the prepared cod carcass, cut into pieces and place in a frying pan with vegetable oil. Cover with grated carrots, finely chopped onions, herbs, and fresh tomatoes cut into slices. Pour boiled water. Close the lid and simmer for 10 minutes. Season with sour cream, simmer for another 5-10 minutes under the lid.

Fish fillet with apples

Ingredients: boiled fish fillet - 500 g, apples - 3-4 pcs., celery - 30 g, onion - 1 pc., egg white - 3 pcs., milk - 1/2 cup.

Grate apples, onions and celery on a coarse grater, mix and place on the bottom of a mold previously greased with vegetable oil. Separate the egg white, beat it with milk; Place the fish fillet on a fruit and vegetable bed and pour the mixture over it. Bake in the oven.

White omelette

Ingredients: egg (white) – 3 pcs., milk – 4 tbsp. l., butter - 1 tbsp. l., sour cream - 1 tbsp. l.

Mix the whites with milk, beat in a mixer or with a whisk, pour into a greased frying pan, sprinkle with sour cream and bake in the oven.

Omelette with greens

Ingredients: egg – 3 pcs., milk – 1/2 cup, parsley and dill, vegetable oil.

Shake eggs with milk, add chopped parsley and dill. Pour the mixture into the frying pan and fry until done.

Sour cream sauce with tomato juice

Ingredients: sour cream -100 g, egg yolk - 2 pcs., tomato - 1 large (100 g).

Cut the ripe tomato in half and, lightly squeezing the juice out of it, rub through a sieve; Add sour cream to the pureed mass, evaporate the resulting mass by 1/3, combine with raw yolks and, stirring quickly, bring to thickening.

Cold green sauce

Ingredients: parsley and dill – 100 g, egg – 2 pcs., table vinegar – 1 tbsp. l., any vegetable oil - 3 tbsp. l.

Finely chop the greens. Boil the eggs, mash the yolks with a fork, and chop the whites; mix eggs with herbs, add vinegar and vegetable oil. The sauce should have a thick consistency.

Jerusalem artichoke pancakes with carrots

Ingredients: Jerusalem artichoke – 500 g, carrots – 500 g, egg – 2 pcs., corn starch.

Grate Jerusalem artichoke and carrots on a fine grater, add eggs, corn starch, mix everything. Spoon the mixture onto a baking sheet and bake in the oven.

Cranberry jelly

Ingredients: cranberries – 200 g, water – 500 ml, sugar, gelatin – 25 g.

Squeeze the juice from the berries, pour boiling water over the juice and boil. Strain the broth, add sugar and swollen gelatin, let the syrup boil, then cool and strain again. Mix with squeezed fresh juice and pour into molds.

Lemon jelly

Ingredients: lemon – 100 g, gelatin – 15 g, sugar – to taste, water – 650 ml.

Bring water to a boil, add lemon zest and leave covered for 10–15 minutes, then strain. Place gelatin soaked in cold water into the hot infusion, let it dissolve, then add lemon juice and sugar, strain, pour into a mold and cool. Place the mold with the cooled jelly in hot water for a second and place the jelly on a saucer.

Recipes for chronic renal failure

You can use recipes for dishes from the previous section, as well as the chapters “Pyelonephritis” and “Glomerulonephritis”, many dishes from the section “Diet for oxalate stones” in the chapter “Kidney stones”.

Carrot and apple salad

Ingredients: carrots – 1 pc., apple – 1 pc., mayonnaise – 1 tbsp. l., parsley.

Grate the peeled carrots and apples on a coarse grater, add parsley, mix and season with mayonnaise.

Parsley and apple salad

Ingredients: parsley root – 100 g, apple – 1 pc., sour cream – 2 tbsp. l., lemon juice.

Grate parsley root, mix with finely chopped apple, season with sour cream, add lemon juice.

Summer vinaigrette

Ingredients: potatoes – 2 pcs., carrots – 1 pc., beets – 1 small, cauliflower – 1 head, fresh cucumber – 1 pc., tomato – 2 pcs., lettuce – 1 bunch, egg – 1 pc., sour cream – 100 ml, sugar – 1 tsp, dill.

Potatoes, beets, carrots, cauliflower boil and cool. Carrots, beets, potatoes, fresh cucumbers peel and cut into thin slices, divide the cauliflower into small pieces, cut the tomatoes into small slices, chop the lettuce, chop the dill. Place the prepared vegetables in a bowl, add sugar, sour cream and mix well (instead of sour cream, the vinaigrette can be seasoned with vegetable oil with the addition of citric acid or mayonnaise). You can add raw zucchini (young), pumpkin, apples, etc. to the vinaigrette.

Beet and apple salad

Ingredients: beets – 1 small, apple – 1 pc., dill, parsley, sour cream – 1 tbsp. l., salt, citric acid to taste.

Cut the boiled beets into strips, and the apple into cubes, mix, season with citric acid and sour cream. Sprinkle with herbs.

Beet tops salad

Ingredients: beet tops – 100 g, green salad – 30 g, parsley, dill, vegetable oil – 1 tbsp. l., egg – 1 pc.

Cut in small pieces beet tops, green salad, a little dill and parsley, add sunflower oil and finely chopped boiled egg.

Cauliflower salad

Ingredients: cauliflower - 150 g, vegetable oil - 1 tbsp. l., boiled egg - 1 pc., greens, green onions.

Boil the cauliflower, separate it into florets, and pour in vegetable oil. Add greens, sprinkle egg on top.

Kohlrabi and apple salad

Ingredients: kohlrabi cabbage – 150 g, apple – 1 pc., sour cream or vegetable oil – 1 tbsp. l., greens.

Finely chop the peeled kohlrabi cabbage and peeled apples, add parsley, vegetable oil, mix and serve immediately.

Appetizer of white cabbage, cucumbers and carrots

Ingredients: white cabbage – 200 g, cucumber – 3 pcs., carrots – 2 pcs., green salad – 1 bunch, mayonnaise – 100 ml, green onions – 1 bunch.

Wash the cabbage and cucumbers and chop finely. Peel the carrots and grate on a coarse grater. Wash and chop the green onions. Wash the lettuce leaves and cover the dish with them. Mix cabbage with cucumbers, carrots and green onions, mix, season with mayonnaise, place on lettuce leaves and serve.

Semolina soup

Ingredients: semolina – 2 tbsp. l., butter – 1 tsp. without top, water - 2 glasses, granulated sugar.

Dilute the sifted semolina with cold water and pour, stirring continuously, into hot water. Boil, stirring constantly, for about 30 minutes. Then sweeten the soup a little.

Before serving, add fresh butter to the soup.

Semolina milk soup with yolk

Ingredients: semolina – 2 tbsp. l., milk - 2 cups, 2 yolks, granulated sugar - 1 tsp, butter - 1 tsp. without top, water - 1 glass.

Dilute the sifted cereal with cold water, add hot water and boil until fully cooked (30 minutes). Pour milk with diluted yolk and sugar into the boiled mass. Add butter to the soup.

Soup “Tender”

Ingredients: young curdled milk – 400 ml, ground peanuts – 50 g, fresh cucumbers – 3 pcs., chopped mint leaves – 2 tbsp. l., green onions - 1 bunch, dill.

Finely chop the cucumbers and place them in a saucepan, add yogurt, chopped mint, dill and finely chopped green onions. Mix everything thoroughly and let the soup cool for an hour. When serving, sprinkle each serving of soup with chopped peanuts.

Potato soup

Ingredients: potatoes – 5 pcs., water – 2 l, milk – 1 glass; for dumplings: egg – 1 pc., milk – 100 ml, flour – 1.5 cups.

Peel the potatoes and boil them in water. Drain the water (but do not pour it out), mash the potatoes, pour hot milk into it, mix thoroughly, add the potato broth, mix well again and put on low heat until it boils.

Prepare the dumpling dough: beat the egg with milk, add flour, the dough should not be too liquid and not too stiff, so that when you take it with a spoon, it does not spread, but retains its shape. Take the dough a little at a time, using a teaspoon dipped in cold water, and throw the dumplings into the boiling broth so that they set immediately. Boil covered for 8-10 minutes. When serving, sprinkle with herbs.

Cream of pearl barley soup

Ingredients: pearl barley – 50 g, milk – 1/2 cup, water – 1 cup, butter – 1 tsp. l., egg – 1 pc.

Rinse the pearl barley well, add cold water and cook until softened. Then salt the cereal and rub it hot through a sieve. Prepare the dressing: grind the yolk with 1 tbsp. l. milk and, continuing to grind, pour in in small portions the rest is milk. Heat the dressing until it boils and gradually, 1 spoon at a time, stirring, add the pureed cereal. Heat the saucepan with soup in a water bath for 10–15 minutes. Add butter to the finished soup.

Puree buckwheat soup

Ingredients: buckwheat – 2 tbsp. l., butter – 1 tsp., milk – 1 glass, water – 2 glasses, egg – 1 pc., olive oil– 1 tsp.

Sort the grains, rinse in running water, add to boiling water and cook until fully cooked. Then rub through a sieve. Place the resulting slurry on the stove, bring to a boil, then set the pan on the edge of the stove. Mix the egg thoroughly, add hot milk and combine with boiling broth; add olive oil, stir. Before serving, add butter to the soup.

Soup "Volynsky"

Ingredients: milk – 2 l, water – 1 glass, carrots – 1 pc., potatoes – 3 pcs., barley – 0.5 cups, sugar – 1 tsp.

Boil barley groats along with potatoes and finely chopped carrots in milk, slightly diluted with water, adding a pinch of sugar.

Cabbage soup with apples

Ingredients: cabbage – 300 g, carrots – 1 pc., rutabaga – 1 pc., parsley root – 1 pc., apple – 1 pc., unsalted tomato paste – 1 tbsp. l., butter – 2 tbsp. l., sour cream.

Place cabbage cut into squares and roots, onions and stewed with butter into boiling broth or water. tomato paste. Cook in a sealed container at low boil until done. Add chopped apple to the prepared cabbage soup and boil. Place sour cream on a plate with cabbage soup.

Vegetable broth with egg white omelette

Ingredients: potatoes - 2 pcs., carrots - 1 pc., parsley root, cabbage stalk - 1 pc., parsley, egg white - 1 pc., milk 10 ml, sour cream - 20 ml, butter - 5 g.

Cut the vegetables into pieces and cook under the lid, let it brew for an hour and strain. Mix the egg white with milk, pour into a greased frying pan and bake, then cool to room temperature and cut the omelette into 5-6 pieces. Season the broth with sour cream and the remaining oil, add an omelette and chopped herbs.

Borscht with vegetable broth

Ingredients: white cabbage - 300 g, beets - 1 pc., potatoes - 4 pcs., carrots - 1 pc., tomato - 1 pc., parsley, butter, sour cream, citric acid - to taste (instead of acid you can put apples or black currants).

Chop the peeled beets into strips, sprinkle with citric acid diluted in water and mix; then add oil and 100 ml of water, close the lid and simmer over low heat for 20-30 minutes, then add chopped carrots, celery, part of the tomato and simmer for another 10 minutes. Add shredded cabbage to the prepared vegetables, add water or vegetable broth, let it boil, add chopped potatoes and cook until tender. Place the remaining tomatoes, cut into slices, into the prepared borscht. Before serving, season with sour cream and sprinkle with chopped herbs.

Vegetable puff soup

Ingredients: sunflower oil – 200 ml, onion – 1 pc., tomatoes – 6 pcs., cabbage – half a head of cabbage, Bell pepper– 4 pcs., potatoes – 4 pcs., zucchini – 2 pcs., carrots – 1 pc., bay leaf.

Pour sunflower oil into the bottom of the goose bowl, put boiled onion rings on the bottom, and put 3 chopped tomatoes on top. Do not mix the layer. The next layer is shredded fresh cabbage. Then - sweet peppers, peeled and cut into rings, on top - chopped potatoes and then diced zucchini and the last layer - 3 chopped tomatoes and grated carrots. Place on low heat; when the vegetables are stewed in oil until tender, pour hot water, add heat and bring to a boil.

Without stirring, carefully place the puff pastry into plates, pour in vegetable broth, add sour cream, sprinkle with chopped herbs.

Brussels sprout soup

Ingredients: Brussels sprouts – 600 g, potatoes – 3–4 pcs., vegetable oil, sour cream.

Place the peeled Brussels sprouts in boiling water for 2 minutes, then drain in a colander, drain, transfer the cabbage to a soup pot with melted butter and lightly fry.

Pour 6-7 cups of hot water over the cabbage, add thinly sliced ​​potatoes and cook over low heat for 20-30 minutes. When serving, add sour cream to the soup.

Cauliflower soup

Ingredients: cauliflower – 600 g or white cabbage – 750 g, potatoes – 7 pcs., oil – 3 tbsp. l., milk - 2 cups.

Select a quarter of the small cauliflower stalks for garnish and cook them separately. Place the rest of the cabbage, as well as peeled and washed potatoes, cut into slices, into a saucepan, add four glasses of water and cook for 25–30 minutes. Rub all this through a sieve and dilute with hot milk. When serving, season the soup with cream or butter, stir and add boiled cabbage stalks. Serve the croutons separately.

Puree soup can also be prepared from white cabbage. It must be cleaned, washed and boiled; After 15–20 minutes, add the potatoes, boil them and then prepare the soup as indicated above.

Cream soup in Flemish style

Ingredients: Brussels sprouts puree – 300 g, potato puree – 300 g, vegetable broth or potato or cabbage broth – 1 l, cream 100 ml, egg – 2 pcs., butter – 50 g.

Combine Brussels sprouts and mashed potatoes and dilute with broth. Season with cream and egg yolks, add butter, heat well, but do not boil.

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Basic principles of diet for kidney failure:

Limit proteins to 20-70g per day, depending on the severity of kidney failure.

Regulation of the intake of table salt, taking into account the severity of edema, hypertension, and protein excretion in the urine.

Providing caloric intake from fats and carbohydrates.

In the initial stage of renal failure, diet No. 7 is prescribed.

Diet for kidney failure in the early stages contains 70 g of protein (of which up to 30% animal proteins) or 60 g of protein, of which 40-50% animal proteins.

Diet for advanced renal failure contains 20g of protein (diet No. 7a) or 40g of protein (diet No. 7b), 70-75% of which are animal proteins from meat, fish, dairy products, eggs. Fluid consumption is 1-1.5 liters per day, but it should correspond to the amount of urine excreted over the previous day, plus 0.4-0.6 liters.

In case of severe renal failure, diet 7a is first prescribed; when the patient’s condition improves, the patient is transferred to diet 7b, against which diet 7a is periodically used.

While using diet 7a, the patient is periodically given 2-4 g of salt on his hands to add salt to the food. When edema appears, salt is again limited to 1 g or eliminated.

The diet for renal failure includes carbohydrate fasting days:

Apple-sugar, rice-compote, potato.

1.Apple-sugar diet: 1.5 kg of ripe or baked apples per day, divided into 5 doses of 300 g, 50-100 g of sugar

2. Rice-compote diet: per day 1.5 fresh fruits or 240g dried fruits, 120g sugar, 50g rice. Cook compote and rice porridge in water. 1 glass of sweet compote 6 times a day, 2 times with sweet rice porridge cooked without salt in water.

3. Potato diet: 1.5 kg of potatoes per day. Boil potatoes in their skins without salt or bake. Eat 300g of potatoes 5 times a day.

4. Special potato diet, prescribed for chronic glomerulonephritis with renal failure: potatoes - 1 kg (net weight), other vegetables or fruits - 300g, vegetable oil - 50g, butter - 70g, sugar - 50g.

Culinary treatment for diet in advanced stages of renal failure:

Culinary processing of products for diets No. 7a and 7b without mechanical sparing.

The food is boiled, followed by baking and light frying.

Diet for renal failure, diet:

Eat food 5-6 times a day.

Food is prepared without salt, bread is given salt-free.

Exclude from the diet for severe renal failure:

1. Regular bread, flour products with added salt.

2. Meat, fish, mushroom broths, milk soups, soups with cereals (except sago) and legumes.

3.All meat and fish products(canned food, sausages).

5. All cereals (limit rice) and pasta.

6. Pickled, salted, pickled vegetables.

7. Sorrel, spinach, cauliflower, legumes, garlic, radish, mushrooms.

8. Chocolate, ice cream, milk jelly.

9. meat, mushroom, fish sauces, mustard, horseradish, pepper.

10. Natural coffee, cocoa, mineral water containing sodium.

11. Pork, beef, lamb fats.

Diet No. 7a:

—Soups vegetarian with sago, vegetable, potato, fruit, taking into account the permitted liquid. Soups are seasoned with sour cream, herbs, boiled and then sautéed onions.

— Meat and fish dishes: 50-60 (gross weight) lean beef or veal, pork (meat without fat), rabbit, chicken, turkey, fish. Boiled meat and fish, baked or lightly fried after boiling, in pieces or chopped.

— Dairy products: 60g of milk, cream, sour cream, cottage cheese - excluding meat and fish.

—Cereals- only sago, limited rice, only protein-free pasta. They prepare dishes with milk or water in the form of porridges, pilaf, cutlets, casseroles, and puddings.

—Eggs: 1/4-1/2 eggs per day (omelet, soft-boiled).

— Vegetables: potatoes 200-250g and fresh vegetables 400-450g (gross weight) in the form of various dishes. Boiled and fried onions as an additive to dishes, dill and parsley.

— Various fruits and berries in raw, dried, baked form, sugar, honey, jam, non-chocolate candies, jelly, compote, jelly.

— To improve taste dishes use greens, sour fruit and vegetable juices.

— Snacks: vegetable salads with vegetable oil.

—Sauces: tomato, sour cream, sweet and sour sauces, vegetable and fruit sauces. Fried onions after boiling, citric acid, cinnamon, vanillin.

.- Fats: unsalted butter, ghee, vegetable oil.

— Flour products: 100g of protein-free, salt-free bread with corn starch, in the absence of such bread, 50g of wheat-free salt-free bread or other salt-free flour products baked with yeast.

—Beverages: fruit and berry juices, tomato juice, rosehip decoction, weak tea with lemon.

Diet 7b:

In diet 7b, the amount of protein is doubled by including 125g of milk and sour cream, 125g of meat or fish, 1 egg. Cottage cheese is given only when meat and fish are excluded or reduced.

Also in diet 7b the amount of potatoes is increased to 300g, other vegetables - to 650g, salt-free, protein-free bread to 150g, sago (rice).

Daily set of products for diet No. 7a(Samsonov M.A. 1981):

Salt-free, protein-free bread - 100g, meat - 62g, eggs - 1/4pcs, milk - 30g, sour cream - 30g, vegetable oil - 7g, butter - 90g, sugar - 80g, sago - 55g, potatoes - 235g, white cabbage - 150g, carrots - 70g, beets - 130g, onions - 30g, green onions - 15g, greens - 10g, radishes - 20g, fresh cucumbers - 20g, parsley - 7g, tomato - 7g, flour - 18g, corn starch - 70g.

Daily set of products for diet No. 7b(Samsonov M.A. 1981):

Protein-free, salt-free bread - 150g, meat - 125g, milk - 80g, eggs - 48g (1 piece), sour cream - 45g, butter - 80g, vegetable oil - 20g, sago - 70g, sugar - 110g, potatoes - 335g, carrots - 80g, white cabbage - 225g, beets - 200g, greens - 20g, green onions - 15g, onions - 40g, green pea- 20g, radishes - 35g, fresh cucumbers - 40g, parsley - 7g, tomato - 15g, flour - 28g, corn starch - 80g.

For acute renal failure as a result of poisoning (for example: sublimate, mercury), acute infections, injuries, acute nephritis, severe burns are prescribed diet 7a (proteins 20-25g), of which animal proteins - 70-75%. The amount of fluid administered should correspond to the amount of urine for the previous day +0.5 l.

The calorie content of the diet should be sufficient to prevent the breakdown of proteins to replenish the body's energy costs.

In end-stage renal failure with a sharp deterioration in kidney function, 20-25 g of protein are prescribed, salt is increased to 8-12 g, free liquid - to 2 liters.

Diet for kidney failure depending on the stage of kidney failure:

1.initial stage- diet No. 7 when replacing protein-free bread (1g protein per 1 kg of patient weight) or diet No. 7 with fasting days with diet 7b (protein 40g, animal - 70-75%) or diet No. 7 (protein 70g, vegetable - 70-75% ).

2.Expressed stage:

— low-symptomatic: diet 7b with periodic administration of diet 7 (load days).

- multi-symptomatic: diet 7b with fasting days diet 7a (protein 20g, of which animals - 70-75%).

3.Final stage:

—uncomplicated: for hemodialysis, diet No. 7 is prescribed with fasting days, diet 7b or diet 7g (protein 60g, of which 75% are animals).

— complicated: diet 7a with loading days diet 7b.

Diet menu No. 7a for 1 day:

1st breakfast: sago milk porridge, apple and carrot cutlets baked in vegetable oil, tea.

2nd breakfast: fresh fruits.

Dinner: 12 servings of vegetarian soup from prefabricated vegetables, boiled potatoes, boiled meat with tomato sauce, jelly.

Afternoon snack: decoction wheat bran with sugar.

Dinner:vegetable salad in vegetable oil, sago pilaf with fruit. Tea.

For the night: fruit juice.

Diet menu No. 7b for 1 day:

1st breakfast: apple and rice pudding, vegetable salad with vegetable oil, tea.

2nd breakfast: raw grated carrots with sugar

Dinner: vegetarian soup made from mixed vegetables (12 servings), boiled potatoes, boiled chicken with milk sauce, dried fruit compote.

Afternoon snack: decoction of wheat bran with sugar.

Dinner: apple pancakes, 1 soft-boiled egg, tea.

Renal failure is a serious complication of various renal pathologies, and a very common one. The disease can be treated, but the organ cannot be restored. Chronic renal failure is not a disease, but a syndrome, that is, a set of signs indicating impaired renal function. The causes of chronic failure can be various diseases or injuries, as a result of which the organ is damaged.

Stages of kidney failure

Water, nitrogen, electrolyte and other types of metabolism in the kidney depend on the functioning of the kidney. human body. Kidney failure is evidence of failure to perform all functions, leading to disruption of all types of balance at once.

Most often, the cause is chronic diseases, in which the kidney parenchyma is slowly destroyed and replaced by connective tissue. Kidney failure becomes the last stage of such ailments - urolithiasis and the like.

The most indicative sign of pathologies is the daily volume of urine - diuresis, or minute. The latter is used when examining the kidneys using the clearance method. With normal kidney function, daily urine output is about 67–75% of the volume of fluid drunk. In this case, the minimum volume required for the organ to function is 500 ml. Therefore, the minimum volume of water that a person should consume per day is 800 ml. With standard water consumption – 1–2 liters per day, daily diuresis is 800–1500 ml.

In renal failure, urine volume changes significantly. In this case, there is both an increase in volume - up to 3000 ml, and a decrease - up to 500 ml. The appearance of daily diuresis of 50 ml is an indicator of kidney failure.

There are acute and chronic renal failure. The first is characterized by the rapid development of the syndrome, pronounced symptoms, severe pain. However, most of the changes that occur with acute renal failure are reversible, allowing renal function to be restored within a few weeks with appropriate treatment.

The chronic form is caused by the slow irreversible replacement of the kidney parenchyma with connective tissue. In this case, it is impossible to restore the functions of the organ, and in later stages surgical intervention is required.

Acute renal failure

Acute renal failure is a sudden, severe disruption of the functionality of an organ associated with suppression of excretory function and the accumulation of nitrogen metabolism products in the blood. In this case, a disorder of water, electrolyte, acid-base, and osmotic balance is observed. Changes of this kind are considered potentially reversible.

ARF develops within a few hours, less often within 1–7 days, and becomes so if the syndrome is observed for more than a day. Acute renal failure is not an independent disease, but a secondary one, developing against the background of other diseases or injuries.

The causes of acute renal failure are:

• low blood flow rate;
• tubular damage;
• obstruction of urine flow due to obstruction;
• destruction of the glomerulus with loss of capillaries and arteries.

The cause of acute renal failure serves as the basis for appropriate qualifications: according to this criterion, prerenal acute failure is distinguished - 70% of all cases, parenchymal - 25% and obstructive - 5%.

According to medical statistics, the causes of such phenomena are:

• surgery or trauma – 60%. The number of cases of this kind is constantly growing, as it is associated with an increase in the number of operations under artificial circulation;
• 40% are treatment related. The use of nephrotoxic drugs, necessary in some cases, leads to development of surge arresters. This category also includes acute poisoning with arsenic, mercury, and mushroom poison;
• 1–2% appear during pregnancy.

Another classification of the stages of the disease is used, related to the patient’s condition; 4 stages are distinguished:

• elementary;
• oligoanuric;
• polyuric;
• recovalescence.

Causes of acute renal failure

initial stage

Signs of the disease depend on the cause and nature of the underlying disease. Caused by stress factors - poisoning, blood loss, injury.

• Thus, with an infectious lesion of an organ, the symptoms coincide with the symptoms of general intoxication - headache, lethargy, muscle weakness, fever may occur. In case of complications intestinal infection Vomiting and diarrhea may occur.
• If acute renal failure is a consequence of poisoning, then anemia, signs of jaundice, and possible seizures are observed.
• If the cause is acute kidney disease - for example, there may be blood in the urine and severe pain in the lower back.

Changes in diuresis at the initial stage are unusual. Pallor, a slight decrease in blood pressure, and a rapid pulse may be observed, but there are no characteristic signs.

Diagnosis at the initial stage is extremely difficult. If acute renal failure is observed against the background of an infectious disease or acute poisoning, the disease is taken into account during treatment, since kidney damage due to poisoning is a completely natural phenomenon. The same can be said for those cases when the patient is prescribed nephrotoxic drugs.

A urine test at the initial stage indicates not so much acute renal failure as it does the factors that provoke the deficiency:

• the relative density for prerenal OPN is higher than 1.018, and for renal OPN is lower than 1.012;
• slight proteinuria and the presence of granular or cellular casts are possible in renal acute renal failure of nephrotoxic origin. However, in 20–30% of cases this sign is absent;
• in case of injury, tumor, infection, urolithiasis, a greater number of red blood cells is detected in the urine;
• a large number of leukocytes indicates an infection or allergic inflammation of the urinary tract;
• if uric acid crystals are found, urate nephropathy can be suspected.

At any stage of acute renal failure, a bacteriological urine test is prescribed.

A general blood test corresponds to the primary disease; a biochemical test at the initial stage can provide evidence of hyperkalemia or hypokalemia. However, mild hyperkalemia – less than 6 mmol/l, does not cause changes.

Clinical picture of the initial stage of acute renal failure

Oligoanuric

This stage in acute renal failure is the most severe and can pose a threat to both life and health. Its symptoms are much better expressed and characteristic, which makes it possible to quickly establish a diagnosis. At this stage, nitrogen metabolism products quickly accumulate in the blood - creatinine, urea, which in a healthy body are excreted in the urine. Potassium absorption decreases, which destroys the water-salt balance. The kidney does not perform the function of maintaining the acid-base balance, resulting in metabolic acidosis.

The main signs of the oligoanuric stage are:

• decreased diuresis: if the daily urine volume drops to 500 ml, this indicates oliguria, if it drops to 50 ml, anuria;
• intoxication with metabolic products - skin itching, nausea, vomiting, tachycardia, rapid breathing;
• noticeable increase blood pressure, conventional antihypertensive drugs do not work;
• confusion, loss of consciousness, possible coma;
• swelling of organs, cavities, subcutaneous tissue. Body weight increases due to fluid accumulation.

The stage lasts from several days - an average of 10-14 - to several weeks. The duration of the period and methods of treatment are determined by the severity of the lesion and the nature of the primary disease.

Symptoms of the oligoanuric stage of acute renal failure

Diagnostics

At this stage, the primary task is to separate anuria from acute urinary retention. To do this, catheterization of the bladder is performed. If no more than 30 ml/hour is still excreted through the catheter, it means that the patient has acute renal failure. To clarify the diagnosis, an analysis of creatinine, urea and potassium in the blood is prescribed.

• With the prerenal form, there is a decrease in sodium and chlorine in the urine, the rate of fractional excretion of sodium is less than 1%. With calcium necrosis in oliguric acute renal failure, the rate increases from 3.5%, in non-oliguric acute renal failure - to 2.3%.
• For differentiation, the ratio of urea in blood and urine, or creatinine in blood and urine is specified. In the prerenal form, the ratio of urea to plasma concentration is 20:1, in the renal form it is 3:1. For creatinine, the ratio will be similar: 40 in urine and 1 in plasma with prerenal acute renal failure and 15:1 with renal acute renal failure.
• In case of renal failure, a characteristic diagnostic sign is a low chlorine content in the blood - less than 95 mmol/l.
• Microscopy data of urinary sediment allows us to judge the nature of the damage. Thus, the presence of non-protein and erythrocyte casts indicates damage to the glomeruli. Brown epithelial casts and loose epithelium indicate. Hemoglobin casts are detected with intratubular blockade.

Since the second stage of acute renal failure provokes severe complications, in addition to urine and blood tests, it is necessary to resort to instrumental methods of analysis:

• , Ultrasound is performed to detect urinary tract obstruction, analyze the size, condition of the kidney, and assess the blood supply. Excretory urography is not performed: radiopaque angiography is prescribed for suspected arterial stenosis;
• chromocystoscopy is prescribed for suspected obstruction of the ureteral orifice;
• Chest radiography is performed to determine pulmonary edema;
• to assess renal perfusion, isotope dynamic scanning of the kidney is prescribed;
• a biopsy is performed in cases where prerenal acute renal failure is excluded and the origin of the disease has not been identified;
• An ECG is prescribed to all patients, without exception, to detect arrhythmia and signs of hyperkalemia.

Treatment of acute renal failure

Treatment is determined by the type of acute renal failure - prerenal, renal, postrenal, and the degree of damage.

The primary task in the prerenal form is to restore blood supply to the kidney, correct dehydration and vascular insufficiency.

• In the renal form, depending on the etiology, it is necessary to stop taking nephrotoxic drugs and take measures to remove toxins. In case of systemic diseases, the administration of glucocorticoids or cytostatics will be required as the cause of acute renal failure. For pyelonephritis and infectious diseases, therapy includes antiviral drugs and antibiotics. In conditions of a hypercalcemic crisis, large volumes of sodium chloride solution, furosemide, and drugs that slow down the absorption of calcium are administered intravenously.
• The condition for the treatment of postrenal acute insufficiency is the elimination of obstruction.

Correction is required water-salt balance. Methods depend on the diagnosis:

• for hyperkalemia above 6.5 mmol/l, a solution of calcium gluconate is administered, and then glucose. If hyperkalemia is refractory, hemodialysis is prescribed;
• To correct hypervolemia, furasemide is administered. The dose is selected individually;
• It is important to observe the total intake of potassium and sodium ions - the value should not exceed daily losses. Therefore, in case of hyponatremia, the volume of fluid is limited, and in case of hypernatremia, sodium chloride solution is administered intravenously;
• the volume of fluid, both consumed and administered intravenously, should generally exceed losses by 400–500 ml.

When the concentration of bicarbonates decreases to 15 meq/l and the blood pH reaches 7.2, acidosis is corrected. Sodium bicarbonate is administered intravenously over 35–40 minutes and then monitored during treatment.

With the non-oliguric form, they try to do without dialysis therapy. But there are a number of indicators for which it is prescribed in any case: symptomatic uremia, hyperkalemia, severe stage of acidemia, pericarditis, accumulation of a large volume of fluid that cannot be removed by medication.

Basic principles of treatment of acute renal failure

Restorative, polyuric

The stage of polyuria appears only with sufficient treatment and is characterized by a gradual restoration of diuresis. At the first stage, the daily volume of urine is fixed at 400 ml, at the stage of polyuria - more than 800 ml.

At the same time, the relative density of urine is still low, the sediment contains a lot of proteins and red blood cells, which indicates restoration of glomerular functions, but indicates damage to the tubular epithelium. The blood remains high in creatinine and urea.

During the treatment process, potassium levels are gradually restored and accumulated fluid is removed from the body. This stage is dangerous because it can lead to hypokalemia, which is no less dangerous than hyperkalemia and can cause dehydration.

The polyuric stage lasts from 2–3 to 10–12 days, depending on the degree of organ damage and is determined by the rate of restoration of the tubular epithelium.

Activities carried out during the oliguric stage continue during recovery. In this case, the doses of drugs are selected and changed individually depending on the test results. Treatment is carried out against the background of a diet: the consumption of proteins, liquids, salt, and so on is limited.

Recovery stage of acute renal failure

Recovery

At this stage, normal diuresis is restored, and, most importantly, the products of nitrogen metabolism are removed. If the pathology is severe or the disease is detected too late, nitrogen compounds may not be eliminated completely, and in this case, acute renal failure may become chronic.

If treatment is ineffective or too late, the terminal stage may develop, which poses a serious threat to life.

The symptoms of the thermal stage are:

• spasms and muscle cramps;
• internal and subcutaneous hemorrhages;
• cardiac dysfunction;
• bloody sputum, shortness of breath and cough caused by the accumulation of fluid in the lung tissues;
• loss of consciousness, coma.

The prognosis depends on the severity of the underlying disease. According to statistics, with an oliguric course the mortality rate is 50%, with a non-oliguric course - 26%. If acute renal failure is not complicated by other diseases, then in 90% of cases they achieve full recovery kidney function over the next 6 weeks.

Symptoms of recovery from acute renal failure

Chronic renal failure

CRF develops gradually and represents a decrease in the number of active nephrons - the structural units of the kidney. The disease is classified as chronic if a decrease in functionality is observed for 3 or more months.

Unlike acute renal failure, chronic renal failure is difficult to diagnose even at later stages, since the disease is asymptomatic, and up to the death of 50% of nephrons, it can only be detected during functional load.

There are many causes of the disease. However, about 75% of them are , and .

Factors that significantly increase the likelihood of chronic renal failure include:

• diabetes;
• smoking;
• obesity;
• systemic infections, as well as acute renal failure;
• infectious diseases of the urinary tract;
• toxic lesions - poisons, drugs, alcohol;
• age-related changes.

However, for a variety of reasons, the mechanism of damage is almost the same: the number of active ones gradually decreases, which provokes the synthesis of angiotensin II. As a result, hyperfiltration and hypertension develop in intact nephrons. In the parenchyma, the renal functional tissue is being replaced by fibrous tissue. Due to the overload of the remaining nephrons, a violation of the water-salt balance, acid-base, protein, carbohydrate metabolism and so on. Unlike acute renal failure, the consequences of chronic renal failure are irreversible: it is impossible to replace a dead nephron.

The modern classification of the disease distinguishes 5 stages, which are determined by the glomerular filtration rate. Another classification is related to the level of creatinine in the blood and urine. This sign is the most characteristic, and from it you can quite accurately determine the stage of the disease.

The most commonly used classification is related to the severity of the patient's condition. It allows you to quickly determine what measures need to be taken first.

Stages of chronic renal failure

Polyuric

The polyuric or initial stage of compensation is asymptomatic. Signs of the primary disease prevail, while there is little evidence of kidney damage.

• Polyuria is the excretion of too much urine, sometimes exceeding the volume of fluid consumed.
• Nocturia is an excess of nocturnal diuresis. Normally, urine is released at night in smaller quantities and is more concentrated. Excretion of more urine at night indicates the need for renal-hepatic tests.
• Even at the initial stage, chronic renal failure is characterized by a decrease in the osmotic density of urine - isosthenuria. If the density is above 1.018, CRF is not confirmed.
• Arterial hypertension is observed in 40–50% of cases. Its difference is that in case of chronic renal failure and other kidney diseases, conventional antihypertensive drugs have little effect on blood pressure.
• Hypokalemia can occur at the stage of polyuria with an overdose of saluretics. It is characterized by severe muscle weakness and changes in the ECG.

Sodium wasting syndrome or sodium retention may develop, depending on tubular reabsorption. Anemia is often observed, and it progresses as other symptoms of chronic renal failure increase. This is due to the fact that when nephrons fail, a deficiency of endogenous epoetin is formed.

Diagnosis includes urine and blood tests. The most revealing of them include the assessment of creatinine content in the blood and urine.

Glomerular filtration rate is also a good determining sign. However, at the polyuric stage, this value is either normal - more than 90 ml/min or slightly reduced - to 69 ml/min.

At the initial stage, treatment is mainly aimed at suppressing the primary disease. It is very important to follow a diet with restrictions on the amount and origin of protein, and, of course, salt intake.

Symptoms of the polyuric stage of chronic renal failure

Stage of clinical manifestations

This stage, also called azotemic or oligoanuric, is different specific disorders in the functioning of the body, indicating noticeable damage to the kidneys:

• The most characteristic symptom is a change in urine volume. If at the first stage more fluid was excreted than normal, then at the second stage of chronic renal failure the volume of urine becomes less and less. Oligouria develops - 500 ml of urine per day, or anuria - 50 ml of urine per day.
• Signs of intoxication increase - vomiting, diarrhea, nausea, the skin becomes pale, dry, and in later stages acquires a characteristic jaundiced tint. Due to urea deposits, patients are worried severe itching, scratched skin practically does not heal.
• Observed severe weakness, weight loss, lack of appetite up to anorexia.
• Due to an imbalance in nitrogen balance, a specific “ammonia” odor appears from the mouth.
• At a later stage, it forms, first on the face, then on the limbs and torso.
• Intoxication and high blood pressure cause dizziness, headaches, and memory impairment.
• A feeling of chills appears in the arms and legs - first in the legs, then their sensitivity decreases. Movement disorders are possible.

These external signs indicate the addition of concomitant diseases and conditions caused by kidney dysfunction to chronic renal failure:

• Azotemia – occurs when there is an increase in nitrogen metabolic products in the blood. Determined by the amount of creatinine in plasma. The uric acid content is not so indicative, since its concentration increases for other reasons.
• Hyperchloremic acidosis is caused by a violation of the mechanism of calcium absorption and is very characteristic of the stage of clinical manifestations; it increases hyperkalemia and hypercatabolism. Its external manifestation is the appearance of shortness of breath and great weakness.
• Hyperkalemia is the most common and most dangerous symptom of chronic renal failure. The kidney is able to maintain the function of potassium absorption until the terminal stage. However, hyperkalemia depends not only on the functioning of the kidney and, if it is damaged, develops in the initial stages. With an excessively high potassium content in plasma - more than 7 mEq/l, nervous and muscle cells lose the ability to excitability, which leads to paralysis, bradycardia, central nervous system damage, acute respiratory failure, and so on.
• With a decrease in appetite and against the background of intoxication, a spontaneous decrease in protein intake occurs. However, its too low content in food for patients with chronic renal failure is no less destructive, since it leads to hypercatabolism and hypoalbuminemia - a decrease in albumin in the blood serum.

Another characteristic symptom for patients with chronic renal failure is an overdose of drugs. For chronic renal failure side effects of any drug are much more pronounced, and overdose occurs in the most unexpected cases. This is due to kidney dysfunction, which is unable to remove waste products, which leads to their accumulation in the blood.

Diagnostics

The main goal of diagnosis is to distinguish chronic renal failure from other kidney diseases with similar symptoms and especially from the acute form. To do this, they resort to various methods.

Of the blood and urine tests, the most informative are the following indicators:

• the amount of creatinine in the blood plasma is more than 0.132 mmol/l;
• – a pronounced decrease is 30–44 ml/min. At a value of 20 ml/min, urgent hospitalization is required;
• urea content in the blood is more than 8.3 mmol/l. If an increase in concentration is observed against the background normal content creatinine, the disease most likely has a different origin.

Among instrumental methods, ultrasound and x-ray methods are used. A characteristic sign of chronic renal failure is reduction and shrinkage of the kidney; if this symptom is not observed, a biopsy is indicated.

X-ray contrast research methods are not permitted

Treatment

Until the end stage, treatment of chronic renal failure does not include dialysis. Conservative treatment is prescribed depending on the degree of kidney damage and associated disorders.

It is very important to continue treatment of the underlying disease, while eliminating nephrotoxic drugs:

• A mandatory part of treatment is a low-protein diet - 0.8-0.5 g/(kg*day). When the albumin content in the serum is less than 30 g/l, the restrictions are weakened, since with such a low protein content the development of nitrogen imbalance is possible; the addition of keto acids and essential amino acids is indicated.
• When GFR is around 25–30 ml/min, thiazide diuretics are not used. With more low values are assigned individually.
• For chronic hyperkalemia, ion-exchange polystyrene resins are used, sometimes in combination with sorbents. In acute cases, calcium salts are administered and hemodialysis is prescribed.
• Correction of metabolic acidosis is achieved by administering 20–30 mmol of sodium bicarbonate intravenously.
• For hyperphosphatemia, substances are used that prevent the absorption of phosphates by the intestine: calcium carbonate, aluminum hydroxide, ketosteryl, phosphocitrile. For hypocalcemia, calcium preparations - carbonate or gluconate - are added to therapy.

Stage of decompensation

This stage is characterized by deterioration of the patient’s condition and the appearance of complications. The glomerular filtration rate is 15–22 ml/min.

• Headaches and lethargy are accompanied by insomnia or, conversely, severe drowsiness. The ability to concentrate is impaired and confusion is possible.
• Peripheral neuropathy progresses - loss of sensation in the arms and legs, up to immobilization. Without hemodialysis, this problem cannot be solved.
• Development of gastric ulcer, appearance of gastritis.
• Chronic renal failure is often accompanied by the development of stomatitis and gingivitis - inflammation of the gums.
• One of the most severe complications of chronic renal failure is inflammation serous membrane heart - pericarditis. It is worth noting that with adequate treatment this complication is rare. Myocardial damage due to hyperkalemia or hyperparathyroidism is observed much more often. The degree of damage to the cardiovascular system is determined by the degree of arterial hypertension.
• Another common complication is pleurisy, that is, inflammation of the pleural layers.
• With fluid retention, blood stagnation in the lungs and swelling are possible. But, as a rule, this complication appears already at the stage of uremia. The complication is detected by x-ray.

Treatment depends on the complications that arise. Possibly connection to conservative hemodialysis therapy.

The prognosis depends on the severity of the disease, age, and timeliness of treatment. At the same time, the prognosis for recovery is questionable, since it is impossible to restore the functions of dead nephrons. However, the prognosis for life is quite favorable. Since the relevant statistics are not kept in the Russian Federation, it is quite difficult to say exactly how many years patients with chronic renal failure live.

In the absence of treatment, the stage of decompensation passes into the terminal stage. And in this case, the patient’s life can only be saved by resorting to kidney transplantation or hemodialysis.

Terminal

The terminal (last) stage is uremic or anuric. Against the background of retention of nitrogen metabolism products and disruption of water-salt, osmotic homeostasis, etc., autointoxication develops. Dystrophy of body tissues and dysfunction of all organs and systems of the body are recorded.

• Symptoms of loss of sensation in the limbs are replaced by complete numbness and paresis.
• There is a high probability of uremic coma and cerebral edema. Against the background of diabetes mellitus, a hyperglycemic coma is formed.
• In the terminal stage, pericarditis is a more frequent complication and is the cause of death in 3–4% of cases.
• Gastrointestinal lesions - anorexia, glossitis, frequent diarrhea. Every 10 patients experience gastric bleeding, which is the cause of death in more than 50% of cases.

Conservative treatment at the terminal stage is powerless.

Depending on the general condition of the patient and the nature of the complications, more effective methods are used:

• – blood purification using an “artificial kidney” device. The procedure is carried out several times a week or every day, has different durations– the regimen is selected by the doctor in accordance with the patient’s condition and development dynamics. The device performs the function of a dead organ, so diagnosed patients cannot live without it.

Hemodialysis today is a more affordable and more effective procedure. According to data from Europe and the USA, the life expectancy of such a patient is 10–14 years. Cases have been recorded where the prognosis is most favorable, since hemodialysis prolongs life by more than 20 years.

• - in this case, the role of the kidney, or, more precisely, the filter, is performed by the peritoneum. The fluid introduced into the peritoneum absorbs the products of nitrogen metabolism and is then removed from the abdomen to the outside. This procedure is carried out several times a day, since its effectiveness is lower than that of hemodialysis.
• - the most effective method, which, however, has a lot of limitations: peptic ulcers, mental illness, endocrine disorders. It is possible to transplant a kidney from either a donor or a cadaveric one.

Recovery after surgery lasts at least 20–40 days and requires the most careful adherence to the prescribed regimen and treatment. A kidney transplant can prolong a patient's life by more than 20 years, unless complications arise.

Stages of creatinine and degree of glomerular filtration reduction

The concentration of creatinine in urine and blood is one of the most characteristic distinctive features chronic renal failure. Another very telling characteristic of a damaged kidney is the glomerular filtration rate. These signs are so important and informative that the classification of chronic renal failure by creatinine or by GFR is used more often than the traditional one.

Classification by creatinine

Creatinine is a breakdown product of creatine phosphate, the main source of energy in muscles. When a muscle contracts, the substance breaks down into creatinine and phosphate, releasing energy. Creatinine then enters the blood and is excreted by the kidneys. Average norm for an adult, the content of the substance in the blood is considered to be 0.14 mmol/l.

An increase in creatinine in the blood causes azotemia - the accumulation of nitrogen breakdown products.

Based on the concentration of this substance, 3 stages of disease development are distinguished:

• Latent - or reversible. Creatinine levels range from 0.14 to 0.71 mmol/L. At this stage, the first uncharacteristic signs of chronic renal failure appear and develop: lethargy, polyuria, and a slight increase in blood pressure. There is a decrease in the size of the kidney. The picture is typical for a condition when up to 50% of nephrons die.
• Azotemic - or stable. The level of the substance varies from 0.72 to 1.24 mmol/l. Coincides with the stage of clinical manifestations. Oligouria develops, headaches, shortness of breath, swelling, muscle spasms And so on. The number of working nephrons decreases from 50 to 20%.
• Uremic stage - or progressive. Characterized by an increase in creatinine concentration above 1.25 mmol/l. Clinical signs are pronounced, complications develop. The number of nephrons is reduced to 5%.

By glomerular filtration rate

Glomerular filtration rate is a parameter used to determine the excretory capacity of an organ. It is calculated in several ways, but the most common involves collecting urine in two hourly portions, determining minute urine output and creatinine concentration. The ratio of these indicators gives the value of glomerular filtration.

GFR classification includes 5 stages:

• Stage 1 – with a normal level of GFR, that is, more than 90 ml/min, signs of renal pathology are observed. At this stage, for cure, sometimes it is enough to eliminate the existing negative factors - smoking, for example;
• Stage 2 – slight decrease in GFR – from 89 to 60 ml/min. At both stages 1 and 2, it is necessary to adhere to a diet, accessible physical activity and periodic observation by a doctor;
• Stage 3A – moderate decrease in filtration rate – from 59 to 49 ml/min;
• Stage 3B – marked decrease to 30 ml/min. At this stage, drug treatment is carried out.
• Stage 4 – characterized by a severe decrease – from 29 to 15 ml/min. Complications appear.
• Stage 5 – GFR is less than 15 ml, the stage corresponds to uremia. The condition is critical.

Stages of chronic renal failure according to glomerular filtration rate


Kidney failure is a severe and very insidious syndrome. At chronic course the first signs of damage to which the patient pays attention appear only when 50% of the nephrons, that is, half of the kidneys, have died. Without treatment, the likelihood of a favorable outcome is extremely low.

A decrease in kidney function until the complete cessation of their filtration capabilities and the ability to remove toxins from the body is chronic renal failure. The etiology of this disease is a consequence of previous diseases or the presence of chronic processes in the body. This kidney damage is especially often diagnosed in older people. Chronic renal failure is a fairly common kidney disease and the number of patients is growing every year.

Pathogenesis and causes of chronic renal failure

• chronic kidney disease - pyelo- or glomerulonephritis;
• systemic disorders metabolic processes- vasculitis, gout, rheumatoid arthritis;
• the presence of cameos or other factors (mucus, pus, blood) blocking the ureter;
• malignant neoplasms of the kidneys;
• neoplasms of the pelvic organs, in which compression of the ureter occurs;
• disorders in the development of the urinary system;
• endocrine diseases (diabetes mellitus);
• vascular diseases (hypertension);
• complications of other diseases (shock, poisoning with toxic drugs);
• alcohol and drug use.

The pathogenesis of this disease is a consequence of the above reasons, in which it develops chronic damage and structural disorders of renal tissue. The process of parenchyma restoration is disrupted, which leads to a decrease in the level of functioning kidney cells. At the same time, the kidney decreases in size and wrinkles.

Symptoms and signs of the disease

Signs of chronic renal failure occur against the background of removing toxins, as well as maintaining metabolic processes, which leads to a malfunction of all systems and organs of the body. Symptoms of chronic renal failure are initially mild, but as the disease progresses, patients experience malaise, fatigue, dry mucous membranes, changes in laboratory tests, insomnia, nervous twitching of the limbs, tremors, numbness of the fingertips. As the disease progresses, the symptoms worsen. Persistent (morning and around the eyes), dry skin, loss of appetite, nausea, and hypertension develop. Forms of chronic renal failure are divided into five stages depending on the severity of the course.

Classification by stages

• Stage 1 CKD is latent. Passes without significant symptoms. Patients do not complain about anything except increased fatigue. In laboratory tests there is a small amount of protein.
• CKD stage 2 - compensated. Patients have the same complaints, but they appear more often. There are changes in laboratory parameters in urine and blood. There is an increase in the daily amount of urine excretion (2.5 l).
• CKD stage 3 - intermittent. There is a further decrease in kidney function. Blood tests show elevated levels of creatinine and urea. There is a deterioration in the condition.
• CKD stage 4 - decompensated. A severe and irreversible change occurs in the functioning of this internal organ.
• CKD stage 5 - end-stage chronic renal failure is characterized by the fact that kidney function almost completely stops. There is a high content of urea and creatinine in the blood. Electrolyte metabolism in the kidneys changes, uremia occurs.

The stages of chronic renal failure are classified depending on the degree of damage to the parenchyma of the organ, its excretory functions and have five degrees. The stages of chronic kidney disease are distinguished according to two criteria - glomerular filtration rate, creatinine and protein level in the urine.

Classification of chronic kidney disease by GFR

Indexation of CKD by albuminuria level

Kidney damage in children

Chronic kidney disease in children is uncommon, but isolated cases do occur. This is a very dangerous disease because it is in childhood that such disorders cause kidney failure, which leads to death. Therefore, identifying chronic renal failure and CKD at the earliest stages is an important task in pediatric nephrology. The causes of CKD in children are:

• low birth weight;
• prematurity;
• abnormalities of intrauterine development;
• renal vein thrombosis in newborns;
• past infectious diseases;
• heredity.

The classification of chronic disease in adults and CKD in children is the same. But the main sign that a child is experiencing this disease, is one that occurs in school-age children. The main manifestation of the syndrome is a sharp disruption of the kidneys and, as a result, severe intoxication of the body. Urgent hospitalization is required.

Complications of the disease

This is a very dangerous disease, the 1st stage of which occurs with hidden symptoms, and the 2nd stage with mild signs of the disease. Chronic renal failure should be treated as early as possible. Chronic renal failure in the initial stage is not characterized by profound changes in the renal tissue. With CKD stage 5, irreversible processes develop that lead to poisoning of the body and deterioration of the patient’s condition. Patients experience arrhythmia, albuminuria, persistent hypertension, anemia, confusion up to coma, nephrogenic hypertension, angiopathy, heart failure and pulmonary edema may develop. Exacerbation of CKD and chronic renal failure leads to uremia. In this case, urine entering the blood leads to uremic shock, which often leads to death.

Diagnosis of the disease

Diagnosis of CKD involves consulting doctors:

• therapist;
• urologist;
• cardiologist;
• endocrinologist;
• ophthalmologist;
• neurologist;
• nephrologist.

The doctor will take a medical history (all symptoms of the disease, accompanying illnesses, in children - the presence of physical developmental delay, as well as features of the family history). Objective examination includes percussion and palpation of the kidneys. In children - examination of the ridge, the presence of weight deficiency, stunted growth, the presence of high blood pressure, signs of anemia, etc. Chronic renal failure is determined by tests:

• Urinalysis - a small amount of protein, decreased density, the presence of red blood cells, casts and an increased number of leukocytes.
• A blood test reveals an increase in leukocytes and ESR, a decreased amount of hemoglobin and red blood cells.
• Biochemical analysis - increased creatinine, urea, nitrogen, potassium and cholesterol in the blood. Decreased protein and calcium.
• Determination of glomerular filtration rate - calculated based on a blood test for creatinine, age, race, gender and other factors.
• An ultrasound of the kidneys and urinary system will help to see the condition of the kidney.
• MRI visualizes the structure of the kidney, its components, ureter and bladder.
• Doppler ultrasound evaluates the condition of the kidney vessels.
• Zimnitsky test - shows the state of kidney function, and you can also see the volume of urine excreted in the morning and afternoon.

Treatment of kidney failure

Initially, treatment of chronic kidney disease is aimed at reducing blood pressure, improving urine formation, lowering the pH of the stomach, and normalizing microelements in the blood. Later, depending on the patient’s condition, hemodialysis, peritoneal dialysis or kidney transplantation are prescribed. With this disease, you should not overcool, lift heavy objects, or succumb to stressful situations. It is very important to adhere proper nutrition. Patients are prescribed diet No. 7. Its main principles are: limited protein intake, reducing the amount of salt and phosphorus in food, reducing and monitoring the amount of potassium, controlling fluid intake (no more than 2 liters), controlling the energy value of food. Nutrition for CKD is not similar to the usual fasting during illness; the menu should include enough fruits and vegetables in the form of soups and compotes.

Limiting protein intake is already recommended at the beginning of the disease - up to 1 g/kg, then - 0.8 g/kg, and at other stages - 0.6 g/kg. Controlling salt intake is a very important point in the diet, since an excess of sodium in the blood leads to hypertension and edema, so it is recommended to consume no more than two grams per day. They also limit the intake of phosphorus to 1 g per day (limit the consumption of foods high in phosphorus). To reduce potassium in the body, which can lead to cardiac arrest, dried fruits, bananas, avocados, potatoes, greens, nuts, chocolate, and legumes are excluded from the diet. The energy value of food should be 2.5-3 thousand calories. The patients' diet is divided (5-6 times, in small portions). The menu should be rich in fruits and vegetables in the form of compotes, soups, etc. Take food boiled or baked.

The diet should include the following products:

• cereals;
• whole grain bread;
• dietary soups;
• meat and fish products from low-fat varieties;
• vegetables and fruits;
• eggs;
• milk, cottage cheese;
• jellies and mousses;
• diluted juice and weak tea, rosehip decoction;
• spices.

Contraindicated:

• salty and spicy foods;
• alcoholic drinks, strong teas, coffee.
• mushrooms;
• greenery;
• legumes and pasta;
• smoked and preserved;
• bananas and dried fruits;
• seasonings: mustard and horseradish;
• garlic and radish.

Treatment of chronic renal failure

Chronic renal failure- a symptom complex caused by a sharp decrease in the number and function of nephrons, which leads to disruption of the excretory and incretory functions of the kidneys, homeostasis, disorders of all types of metabolism, blood sugar, and the activity of all organs and systems.

For the correct selection of adequate treatment methods, it is extremely important to take into account the classification of chronic renal failure.

1. Conservative stage with a drop in glomerular filtration to 40-15 ml/min with great possibilities for conservative treatment.

2. Terminal stage with glomerular filtration rate of about 15 ml/min, when the issue of extrarenal cleansing (hemodialysis, peritoneal dialysis) or kidney transplantation should be discussed.

1. Treatment of chronic renal failure in the conservative stage

Treatment program for chronic renal failure in the conservative stage.
1. Treatment of the underlying disease that led to uremia.
2. Mode.
3. Medical nutrition.
4. Adequate fluid intake (correction of water balance disorders).
5. Correction of electrolyte metabolism disorders.
6. Reducing the retention of end products of protein metabolism (combat azotemia).
7. Correction of acidosis.
8. Treatment of arterial hypertension.
9. Treatment of anemia.
10. Treatment of uremic osteodystrophy.
11. Treatment of infectious complications.

1.1. Treatment of the underlying disease

Treatment of the underlying disease that led to the development of chronic renal failure in a conservative stage can still have a positive effect and even reduce the severity of chronic renal failure. This especially applies to chronic pyelonephritis with initial or moderate symptoms of chronic renal failure. Stopping the exacerbation of the inflammatory process in the kidneys reduces the severity of renal failure.

1.2. Mode

The patient should avoid hypothermia, heavy physical and emotional stress. The patient needs optimal working and living conditions. He must be surrounded by attention and care, he must be given additional rest during work, and a longer vacation is also advisable.

1.3. Medical nutrition

The diet for chronic renal failure is based on the following principles:

• limiting dietary protein intake to 60-40-20 g per day, depending on the severity of renal failure;
• ensuring sufficient calorie content of the diet corresponding to the energy needs of the body, due to fats, carbohydrates, complete provision of the body with microelements and vitamins;
• limiting the intake of phosphates from food;
• control over the intake of sodium chloride, water and potassium.

The implementation of these principles, especially the restriction of protein and phosphates in the diet, reduces the additional load on functioning nephrons, contributes to a longer preservation of satisfactory renal function, reduces azotemia, and slows down the progression of chronic renal failure. Limiting protein in food reduces the formation and retention of nitrogenous waste in the body, reduces the content of nitrogenous waste in the blood serum due to a decrease in the formation of urea (with the breakdown of 100 g of protein, 30 g of urea is formed) and due to its reutilization.

In the early stages of chronic renal failure, when the level of creatinine in the blood is up to 0.35 mmol/l and urea up to 16.7 mmol/l (glomerular filtration about 40 ml/min), moderate protein restriction to 0.8-1 g/kg is recommended, i.e. up to 50-60 g per day. At the same time, 40 g should be high-value protein in the form of meat, poultry, eggs, and milk. It is not recommended to overuse milk and fish due to their high phosphate content.

When serum creatinine levels are from 0.35 to 0.53 mmol/l and urea levels are 16.7-20.0 mmol/l (glomerular filtration rate is about 20-30 ml/min), protein should be limited to 40 g per day (0.5-0.6 g/kg). At the same time, 30 g should be high-value protein, and bread, cereals, potatoes and other vegetables should account for only 10 g of protein per day. 30-40 g of complete protein per day is the minimum amount of protein required to maintain a positive nitrogen balance. If a patient with chronic renal failure has significant proteinuria, the protein content in food is increased according to the loss of protein in the urine, adding one egg (5-6 g of protein) for every 6 g of urine protein. In general, the patient’s menu is compiled within table No. 7. The patient’s daily diet includes the following products: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina porridge, rice, buckwheat, pearl barley. Particularly suitable due to their low protein content and at the same time high energy value are potato dishes (pancakes, cutlets, babkas, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar per glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and, in doses, proteins. Calculating the daily amount of protein in the diet is mandatory. When compiling a menu, you should use tables reflecting the protein content of the product and its energy value ( table 1 ).

Table 1. Protein content and energy value
some food products (per 100 g of product)

Table 2. Approximate daily set of foods (diet No. 7)
per 50 g of protein for chronic renal failure

An approximate version of diet No. 7 for 40 g of protein per day:

The potato and potato-egg diets have become widespread in the treatment of patients with chronic renal failure. These diets are high in calories due to protein-free foods - carbohydrates and fats. High calorie food reduces catabolism and reduces the breakdown of your own protein. Honey, sweet fruits (poor in protein and potassium), vegetable oil, lard (in the absence of edema and hypertension) can also be recommended as high-calorie foods. There is no need to prohibit alcohol in chronic renal failure (with the exception of alcoholic nephritis, where abstinence from alcohol can lead to improved kidney function).

1.4. Correction of water balance disorders

If the level of creatinine in the blood plasma is 0.35-1.3 mmol/l, which corresponds to a glomerular filtration rate of 10-40 ml/min, and there are no signs of heart failure, then the patient should take enough fluid to maintain diuresis within 2-2.5 l per day. day. In practice, we can assume that under the above conditions there is no need to limit fluid intake. This water regime makes it possible to prevent dehydration and at the same time release an adequate amount of fluid due to osmotic diuresis in the remaining nephrons. In addition, high diuresis reduces the reabsorption of waste in the tubules, promoting their maximum excretion. Increased fluid flow in the glomeruli increases glomerular filtration. When the glomerular filtration rate is more than 15 ml/min, the risk of fluid overload during oral administration is minimal.

In some cases, with the compensated stage of chronic renal failure, symptoms of dehydration may appear due to compensatory polyuria, as well as vomiting and diarrhea. Dehydration can be cellular (excruciating thirst, weakness, drowsiness, reduced skin turgor, sunken face, very dry tongue, increased blood viscosity and hematocrit, possibly increased body temperature) and extracellular (thirst, asthenia, dry sagging skin, sunken face, arterial hypotension , tachycardia). With the development of cellular dehydration, intravenous administration of 3-5 ml of 5% glucose solution per day under the control of central venous pressure is recommended. For extracellular dehydration, an isotonic sodium chloride solution is administered intravenously.

1.5. Correction of electrolyte imbalances

The intake of table salt in patients with chronic renal failure without edema syndrome and arterial hypertension should not be limited. Sharp and prolonged salt restriction leads to dehydration of patients, hypovolemia and deterioration of kidney function, increasing weakness, and loss of appetite. The recommended amount of salt in the conservative phase of chronic renal failure in the absence of edema and arterial hypertension is 10-15 g per day. With the development of edema syndrome and severe arterial hypertension, the consumption of table salt should be limited. Patients with chronic glomerulonephritis with chronic renal failure are allowed 3-5 g of salt per day, with chronic pyelonephritis with chronic renal failure - 5-10 g per day (in the presence of polyuria and the so-called salt-losing kidney). It is advisable to determine the amount of sodium excreted in the urine per day in order to calculate the required amount of table salt in the diet.

In the polyuric phase of chronic renal failure, pronounced losses of sodium and potassium in the urine may occur, which leads to the development hyponatremia And hypokalemia.

In order to accurately calculate the amount of sodium chloride (in g) a patient needs per day, you can use the formula: amount of sodium excreted in urine per day (in g) X 2.54. Practically, 5-6 g of table salt per 1 liter of urine excreted is added to the patient’s food. The amount of potassium chloride needed per day by a patient to prevent the development of hypokalemia in the polyuric phase of chronic renal failure can be calculated using the formula: amount of potassium excreted in urine per day (in g) X 1.91. When hypokalemia develops, the patient is given vegetables and fruits rich in potassium (Table 43), as well as potassium chloride orally in the form of a 10% solution, based on the fact that 1 g of potassium chloride (i.e. 10 ml of a 10% solution of potassium chloride) contains 13.4 mmol potassium or 524 mg potassium (1 mmol potassium = 39.1 mg).

With moderate hyperkalemia(6-6.5 mmol/l) foods rich in potassium should be limited in the diet, potassium-sparing diuretics should be avoided, and ion exchange resins should be taken ( resonium 10 g 3 times a day per 100 ml of water).

For hyperkalemia of 6.5-7 mmol/l, it is advisable to add intravenous glucose with insulin (8 units of insulin per 500 ml of 5% glucose solution).

With hyperkalemia above 7 mmol/l there is a risk of cardiac complications (extrasystole, atrioventricular block, asystole). In this case, in addition to intravenous administration of glucose with insulin, intravenous administration of 20-30 ml of 10% calcium gluconate solution or 200 ml of 5% sodium bicarbonate solution is indicated.

For measures to normalize calcium metabolism, see the section “Treatment of uremic osteodystrophy.”

Table 3. Potassium content in 100 g of products

1.6. Reducing the retention of end products of protein metabolism (combat azotemia)

1.6.1. Diet
For chronic renal failure, a low protein diet is used (see above).

7.6.2. Sorbents
Sorbents used along with the diet adsorb ammonia and other toxic substances in the intestines.
Most often used as sorbents enterodesis or carbolene 5 g per 100 ml of water 3 times a day 2 hours after meals. Enterodes is a low molecular weight polyvinylpyrrolidone preparation that has detoxification properties, binds toxins entering the gastrointestinal tract or formed in the body, and removes them through the intestines. Sometimes oxidized starch in combination with coal is used as sorbents.
Widely used in chronic renal failure enterosorbents- various types of activated carbon for oral administration. You can use enterosorbents of the IGI, SKNP-1, SKNP-2 brands at a dose of 6 g per day. Enterosorbent is produced in the Republic of Belarus Belosorb-II, which is used 1-2 g 3 times a day. The addition of sorbents increases the excretion of nitrogen in feces and leads to a decrease in the concentration of urea in the blood serum.

1.6.3. Colon lavage, intestinal dialysis
With uremia, up to 70 g of urea, 2.9 g of creatinine, 2 g of phosphates and 2.5 g of uric acid are released into the intestines per day. By removing these substances from the intestines, intoxication can be reduced, so intestinal lavage, intestinal dialysis, and siphon enemas are used to treat chronic renal failure. Intestinal dialysis is the most effective. It is performed using a two-channel probe up to 2 m long. One channel of the probe is designed to inflate a balloon, with which the probe is fixed in the intestinal lumen. The probe is inserted under X-ray control into the jejunum, where it is fixed with a balloon. Through another channel of the probe, 8-10 liters of hypertonic solution of the following composition are introduced into the small intestine over 2 hours in equal portions: sucrose - 90 g/l, glucose - 8 g/l, potassium chloride - 0.2 g/l, sodium bicarbonate - 1 g /l, sodium chloride - 1 g/l. Intestinal dialysis is effective for moderate symptoms of uremic intoxication.

In order to develop a laxative effect and thereby reduce intoxication, they are used sorbitol And xylitol. When they are administered orally in a dose of 50 g, severe diarrhea develops with the loss of a significant amount of liquid (3-5 liters per day) and nitrogenous waste.

If hemodialysis is not possible, the method of controlled forced diarrhea using hyperosmolar Young's solution the following composition: mannitol - 32.8 g/l, sodium chloride - 2.4 g/l, potassium chloride - 0.3 g/l, calcium chloride - 0.11 g/l, sodium bicarbonate - 1.7 g/l. Within 3 hours you should drink 7 liters of warm solution (1 glass every 5 minutes). Diarrhea begins 45 minutes after starting to take Young's solution and ends 25 minutes after stopping taking it. The solution is taken 2-3 times a week. It tastes good. Mannitol can be replaced with sorbitol. After each procedure, urea in the blood decreases by 37.6%. potassium - by 0.7 mmol/l, the level of bicarbonates increases, krsatinina - does not change. The duration of treatment is from 1.5 to 16 months.

1.6.4. Gastric lavage (dialysis)
It is known that with a decrease in the nitrogen excretory function of the kidneys, urea and other products of nitrogen metabolism begin to be released by the gastric mucosa. In this regard, gastric lavage can reduce azotemia. Before gastric lavage, the level of urea in the gastric contents is determined. If the level of urea in the gastric contents is 10 mmol/l or more less than the level in the blood, the excretory capabilities of the stomach are not exhausted. 1 liter of 2% sodium bicarbonate solution is injected into the stomach, then sucked off. Washing is done in the morning and evening. In 1 session you can remove 3-4 g of urea.

1.6.5. Antiazotemic agents
Antiazotemic agents have the ability to increase the secretion of urea. Despite the fact that many authors consider their anti-azotemic effect to be problematic or very weak, these drugs have gained great popularity among patients with chronic renal failure. In the absence of individual intolerance, they can be prescribed in the conservative stage of chronic renal failure.
Hofitol- purified extract of the cinara scolymus plant, available in ampoules of 5-10 ml (0.1 g of pure substance) for intravenous and intramuscular administration, course of treatment - 12 injections.
Lespenefril- obtained from the stems and leaves of the legume plant Lespedesa capitata, available in the form of an alcohol tincture or lyophilized extract for injection. It is used orally at 1-2 teaspoons per day, in more severe cases - starting from 2-3 to 6 teaspoons per day. For maintenance therapy, it is prescribed for a long time - 1 teaspoon every other day. Lespenefril is also available in ampoules in the form of lyophilized powder. Administered intravenously or intramuscularly (an average of 4 ampoules per day). It is also administered intravenously in an isotonic sodium chloride solution.

1.6.6. Anabolic drugs
Anabolic drugs are used to reduce azotemia in the initial stages of chronic renal failure; when treated with these drugs, urea nitrogen is used for protein synthesis. Recommended retabolil 1 ml intramuscularly 1 time per week for 2-3 weeks.

1.6.7. Parenteral administration of detoxification agents
Hemodez, 5% glucose solution, etc. are used.

1.7. Correction of acidosis

Acidosis usually does not produce clear clinical manifestations. The need for its correction is due to the fact that with acidosis, bone changes may develop due to the constant retention of hydrogen ions; in addition, acidosis contributes to the development of hyperkalemia.

In moderate acidosis, protein restriction in the diet leads to an increase in pH. In mild cases, to relieve acidosis, you can use soda (sodium bicarbonate) orally in a daily dose of 3-9 g or sodium lactate 3-6 g per day. Sodium lactate is contraindicated in cases of liver dysfunction, heart failure and other conditions accompanied by the formation of lactic acid. In mild cases of acidosis, you can also use sodium citrate orally in a daily dose of 4-8 g. In case of severe acidosis, sodium bicarbonate is administered intravenously in the form of a 4.2% solution. The amount of 4.2% solution required to correct acidosis can be calculated as follows: 0.6 x BE x body weight (kg), where BE is the deficiency of buffer bases (mmol/l). If it is not possible to determine the shift of buffer bases and calculate their deficiency, you can administer a 4.2% soda solution in an amount of about 4 ml/kg. I. E. Tareeva draws attention to the fact that intravenous administration of a soda solution in an amount of more than 150 ml requires special caution due to the risk of depression of cardiac activity and the development of heart failure.

When using sodium bicarbonate, acidosis is reduced and, as a result, the amount of ionized calcium also decreases, which can lead to seizures. In this regard, intravenous administration of 10 ml of 10% calcium gluconate solution is advisable.

Often used in the treatment of severe acidosis. trisamine. Its advantage is that it penetrates the cell and corrects intracellular pH. However, many consider the use of trisamine contraindicated in cases of impaired renal excretory function; in these cases, severe hyperkalemia is possible. Therefore, trisamine has not received widespread use as a means to relieve acidosis in chronic renal failure.

Relative contraindications to alkali infusions are: edema, heart failure, high arterial hypertension, hypernatremia. For hypernatremia, the combined use of soda and 5% glucose solution in a ratio of 1:3 or 1:2 is recommended.

1.8. Treatment of arterial hypertension

It is necessary to strive to optimize blood pressure, since hypertension sharply worsens the prognosis and reduces the life expectancy of patients with chronic renal failure. Blood pressure should be kept within 130-150/80-90 mmHg. Art. In most patients with a conservative stage of chronic renal failure, arterial hypertension is moderately expressed, i.e. systolic blood pressure ranges from 140 to 170 mm Hg. Art., and diastolic - from 90 to 100-115 mm Hg. Art. Malignant arterial hypertension in chronic renal failure is observed infrequently. The reduction in blood pressure should be carried out under the control of diuresis and glomerular filtration. If these indicators decrease significantly with a decrease in blood pressure, the dose of drugs should be reduced.

Treatment of patients with chronic renal failure with arterial hypertension includes:

Restriction in the diet of table salt to 3-5 g per day, with severe arterial hypertension - to 1-2 g per day, and as soon as blood pressure normalizes, salt intake should be increased.

Prescription of natriuretics - furosemide at a dose of 80-140-160 mg per day, uregita(ethacrynic acid) up to 100 mg per day. Both drugs slightly increase glomerular filtration. These drugs are used in tablets, and for pulmonary edema and other urgent conditions - intravenously. In large doses, these drugs can cause hearing loss and increase the toxic effect of cephalosporins. If the antihypertensive effect of these diuretics is insufficient, any of them can be combined with hypothiazide (25-50 mg orally in the morning). However, hypothiazide should be used at creatinine levels up to 0.25 mmol/l; at higher creatinine levels, hypothiazide is ineffective, and the risk of hyperuricemia increases.

Prescribing antihypertensive drugs with predominantly central adrenergic action - dopegite And clonidine. Dopegite is converted into alphamethylnorepinephrine in the central nervous system and causes a decrease in blood pressure by enhancing the depressant effects of the paraventricular nucleus of the hypothalamus and stimulating the postsynaptic α-adrenergic receptors of the medulla oblongata, which leads to a decrease in the tone of the vasomotor centers. Dopegit can be used in a dose of 0.25 g 3-4 times a day, the drug increases glomerular filtration, however, its elimination in chronic renal failure is significantly slowed down and its metabolites can accumulate in the body, causing a number of side effects, in particular, depression of the central nervous system and a decrease in myocardial contractility, therefore, the daily dose should not exceed 1.5 g. Clonidine stimulates α-adrenergic receptors of the central nervous system, which leads to inhibition of sympathetic impulses from the vasomotor center to the medullary substance and medulla oblongata, which causes a decrease in blood pressure. The drug also reduces the content of renin in the blood plasma. Clonidine is prescribed at a dose of 0.075 g 3 times a day; if the hypotensive effect is insufficient, the dose is increased to 0.15 mg 3 times a day. It is advisable to combine dopegit or clonidine with saluretics - furosemide, hypothiazide, which allows you to reduce the dose of clonidine or dopegit and reduce the side effects of these drugs.

In some cases, it is possible to use beta-blockers ( anaprilina, obsidan, inderala). These drugs reduce the secretion of renin, their pharmacokinetics in chronic renal failure are not affected, therefore I. E. Tareeva allows their use in large daily doses - up to 360-480 mg. However, such large doses are not always required. It is better to take smaller doses (120-240 mg per day) to avoid side effects. The therapeutic effect of the drugs is enhanced when combined with saluretics. When arterial hypertension is combined with heart failure during treatment with beta-blockers, caution should be exercised.

In the absence of a hypotensive effect from the above measures, it is advisable to use peripheral vasodilators, since these drugs have a pronounced hypotensive effect and increase renal blood flow and glomerular filtration. Applicable prazosin(minipress) 0.5 mg 2-3 times a day. ACE inhibitors are especially indicated - hood(captopril) 0.25-0.5 mg/kg 2 times a day. The advantage of capoten and its analogues is their normalizing effect on intraglomerular hemodynamics.

For arterial hypertension refractory to treatment, ACE inhibitors are prescribed in combination with saluretics and beta blockers. Doses of drugs are reduced as chronic renal failure progresses, the glomerular filtration rate and the level of azotemia are constantly monitored (if the renovascular mechanism of arterial hypertension predominates, filtration pressure and glomerular filtration rate decrease).

To relieve a hypertensive crisis in chronic renal failure, furosemide or verapamil is administered intravenously, captopril, nifedipine or clonidine are used sublingually. If there is no effect from drug therapy, extracorporeal methods for removing excess sodium are used: isolated blood ultrafiltration, hemodialysis (I. M. Kutyrina, N. L. Livshits, 1995).

Often, a greater effect of antihypertensive therapy can be achieved not by increasing the dose of one drug, but by a combination of two or three drugs acting on various pathogenetic links of hypertension, for example, a saluretic and a sympatholytic, a beta blocker and a saluretic, a centrally acting drug and a saluretic, etc.

1.9. Treatment of anemia

Unfortunately, treatment of anemia in patients with chronic renal failure is not always effective. It should be noted that most patients with chronic renal failure tolerate anemia satisfactorily with a decrease in hemoglobin levels even to 50-60 g/l, as adaptive reactions develop that improve the oxygen transport function of the blood. The main directions of treatment of anemia in chronic renal failure are as follows.

1.9.1. Treatment with iron supplements
Iron preparations are usually taken orally and only in case of poor tolerance and gastrointestinal disorders they are administered intravenously or intramuscularly. Most often prescribed ferroplex 2 tablets 3 times a day after meals; ferrocerone conference 2 tablets 3 times a day; ferrograduate, tardiferon(extended-release iron preparations) 1-2 tablets 1-2 times a day ( table 4 ).

Table 4. Oral preparations containing ferrous iron

Iron supplements should be dosed based on the fact that the minimum effective daily dose of ferrous iron for an adult is 100 mg, and the maximum appropriate daily dose is 300-400 mg. Therefore, it is necessary to begin treatment with minimal doses, then gradually, if the drugs are well tolerated, the dose is increased to the maximum appropriate. The daily dose is taken in 3-4 doses, and extended-release drugs are taken 1-2 times a day. Iron supplements are taken 1 hour before meals or no earlier than 2 hours after meals. The total duration of treatment with oral medications is at least 2-3 months, and often up to 4-6 months, which is required to fill the depot. After reaching a hemoglobin level of 120 g/l, taking the drugs continues for at least 1.5-2 months, in the future it is possible to switch to maintenance doses. However, it is, of course, usually not possible to normalize hemoglobin levels due to the irreversibility of the pathological process underlying chronic renal failure.

1.9.2. Androgen treatment
Androgens activate erythropoiesis. They are prescribed to men in relatively large doses - testosterone intramuscularly 400-600 mg of 5% solution once a week; Sustanon, testenate intramuscularly 100-150 mg of 10% solution 3 times a week.

1.9.3. Treatment with Recormon
Recombinant erythropoietin - Recormon is used to treat erythropoietin deficiency in patients with chronic renal failure. One ampoule of the drug for injection contains 1000 IU. The drug is administered only subcutaneously, the initial dose is 20 IU/kg 3 times a week, then, if there is no effect, the number of injections is increased by 3 every month. The maximum dose is 720 units/kg per week. After an increase in hematocrit by 30-35%, a maintenance dose is prescribed, which is equal to half the dose at which the hematocrit increased, the drug is administered at 1-2 week intervals.

Side effects of Recormon: increased blood pressure (in case of severe arterial hypertension, the drug is not used), increased platelet count, the appearance of a flu-like syndrome at the beginning of treatment (headache, joint pain, dizziness, weakness).

Treatment with erythropoietin is currently the most effective method of treating anemia in patients with chronic renal failure. It has also been established that treatment with erythropoietin has a positive effect on the function of many endocrine organs (F. Kokot, 1991): renin activity is suppressed, the level of aldosterone in the blood decreases, the level of atrial natriuretic factor in the blood increases, and the levels of growth hormone, cortisol, prolactin, ACTH also decrease , pancreatic polypeptide, glucagon, gastrin, the secretion of testosterone increases, which, along with a decrease in prolactin, has a positive effect on the sexual function of men.

1.9.4. Red blood cell transfusion
Transfusion of red blood cells is performed in cases of severe anemia (hemoglobin level below 50-45 g/l).

1.9.5. Multivitamin therapy
It is advisable to use balanced multivitamin complexes (undevit, oligovit, duovit, dekamevit, fortevit, etc.).

1.10. Treatment of uremic osteodystrophy

1.10.1. Maintaining close to normal levels of calcium and phosphorus in the blood
Typically, calcium levels in the blood are low and phosphorus levels are high. The patient is prescribed calcium supplements in the form of the most easily absorbed calcium carbonate in a daily dose of 3 g with a glomerular filtration rate of 10-20 ml/min and about 5 g per day with a glomerular filtration rate of less than 10 ml/min.
It is also necessary to reduce the intake of phosphates from food (they are found mainly in protein-rich foods) and prescribe drugs that reduce the absorption of phosphates in the intestine. It is recommended to take Almagel 10 ml 4 times a day; it contains aluminum hydroxide, which forms insoluble compounds with phosphorus that are not absorbed in the intestines.

1.10.2. Suppressing overactive parathyroid glands
This principle of treatment is carried out by taking calcium orally (based on the feedback principle, this inhibits the function of the parathyroid glands), as well as taking medications vitamin D- oil or alcohol solution of vitamin D (ergocalciferol) in a daily dose of 100,000 to 300,000 IU; more efficient vitamin D 3(Oxidevit), which is prescribed in capsules at 0.5-1 mcg per day.
Vitamin D preparations significantly enhance the absorption of calcium in the intestine and increase its level in the blood, which inhibits the function of the parathyroid glands.
Close to vitamin D, but has a more energetic effect tahistin- 10-20 drops of 0.1% oil solution 3 times a day orally.
As the level of calcium in the blood increases, the dosage of the drugs is gradually reduced.
For advanced uremic osteodystrophy, subtotal parathyroidectomy may be recommended.

1.10.3. Treatment with osteoquin
In recent years, a drug has appeared osteoquin(ipriflavone) for the treatment of osteoporosis of any origin. The proposed mechanism of its action is inhibition of bone resorption by enhancing the action of endogenous calcitonin and improving mineralization due to calcium retention. The drug is prescribed at a dose of 0.2 g 3 times a day for an average of 8-9 months.

1.11. Treatment of infectious complications

The appearance of infectious complications in patients with chronic renal failure leads to a sharp decrease in renal function. If there is a sudden drop in glomerular filtration rate in a nephrology patient, the possibility of infection must first be excluded. When carrying out antibacterial therapy, one should remember the need to reduce doses of drugs, taking into account the impairment of renal excretory function, as well as the nephrotoxicity of a number of antibacterial agents. The most nephrotoxic antibiotics are aminoglycosides (gentamicin, kanamycin, streptomycin, tobramycin, brulamycin). The combination of these antibiotics with diuretics increases the possibility of toxic effects. Tetracyclines are moderately nephrotoxic.

The following antibiotics are not nephrotoxic: chloramphenicol, macrolides (erythromycin, oleandomycin), oxacillin, methicillin, penicillin and other drugs of the penicillin group. These antibiotics can be prescribed in normal doses. For urinary tract infections, preference is also given to cephalosporins and penicillins secreted by tubules, which ensures their sufficient concentration even with a decrease in glomerular filtration ( table 5 ).

Nitrofuran compounds and nalidixic acid preparations can be prescribed for chronic renal failure only in the latent and compensated stages.

Table 5. Doses of antibiotics for various degrees of renal failure

Note: in case of significant impairment of renal function, the use of aminoglycosides (gentamicin, kanamycin, streptomycin) is not recommended.

2. Basic principles of treatment of end-stage chronic renal failure

2.1. Mode

The regimen for patients with end-stage chronic renal failure should be as gentle as possible.

2.2. Medical nutrition

In the terminal stage of chronic renal failure with a glomerular filtration rate of 10 ml/min and below and with a urea level in the blood of more than 16.7 mmol/l with severe symptoms intoxication, diet No. 7 is prescribed with a protein limit to 0.25-0.3 g/kg, a total of 20-25 g of protein per day, and 15 g of protein should be complete. It is also advisable to take essential amino acids (especially histidine, tyrosine), their keto analogues, and vitamins.

The principle of the therapeutic effect of a low-protein diet lies primarily in the fact that in case of uremia, low amino acid content in plasma and low protein intake from food, urea nitrogen is used in the body for the synthesis of essential amino acids and protein. A diet containing 20-25 g of protein is prescribed to patients with chronic renal failure only for a limited time - for 20-25 days.

As the concentration of urea and creatinine in the blood decreases, intoxication and dyspeptic symptoms decrease in patients, the feeling of hunger increases, and they begin to lose body weight. During this period, patients are transferred to a diet containing 40 g of protein per day.

Options for a low-protein diet according to A. Dolgodvorov(proteins 20-25 g, carbohydrates - 300-350 g, fats - 110 g, calories - 2500 kcal):

Separately, patients are given histidine at a dose of 2.4 g per day.

Options for a low-protein diet according to S. I. Ryabov(proteins - 18-24 g, fats - 110 g, carbohydrates - 340-360 g, sodium - 20 mmol, potassium - 50 mmol, calcium 420 mg, phosphorus - 450 mg).
With each option, the patient receives 30 g of butter, 100 g of sugar, 1 egg, 50-100 g of jam or honey, 200 g of protein-free bread per day. Sources of amino acids in the diet are eggs, fresh vegetables, fruits, in addition, 1 g of methionine is given per day. Adding spices is allowed: bay leaf, cinnamon, cloves. Can be consumed a small amount of dry grape wine. Meat and fish are prohibited.

N.A. Ratner suggests using potato diet as a low-protein diet. Wherein high calorie content achieved through protein-free foods - carbohydrates and fats ( table 6 ).

Table 6. Low-protein potato diet (N. A. Ratner)

The diet is well tolerated by patients, but is contraindicated if there is a tendency to hyperkalemia.

S.I. Ryabov developed variants of diet No. 7 for patients with chronic renal failure who are on hemodialysis. This diet has been expanded due to the loss of amino acids during hemodialysis, so S.I. Ryabov suggests including a small amount of meat and fish in the diet (up to 60-70 g of protein per day during hemodialysis).

A promising addition to a low-protein diet is the use of sorbents, as in the conservative stage of chronic renal failure: oxycellulose in an initial dose of 40 g, followed by increasing the dose to 100 g per day; starch 35 g daily for 3 weeks; polyaldehyde "polyacromene" 40-60 g per day; carbolene 30 g per day; enterodesis; coal enterosorbents.

Completely protein-free diets are also offered (for 4-6 weeks) with the introduction of only essential acids or their keto analogues (ketosteril, ketoperlene) from nitrogenous substances. When using such diets, the content of urea first decreases, and then uric acid, methylguanidine and, to a lesser extent, creatinine, and the level of hemoglobin in the blood may increase.

The difficulty of following a low-protein diet lies primarily in the need to exclude or sharply limit foods containing vegetable protein: bread, potatoes, cereals. Therefore, you should take low-protein bread made from wheat or corn starch (100 g of such bread contains 0.78 g of protein) and artificial sago (0.68 g of protein per 100 g of product). Sago is used instead various cereals.

2.3. Controlling fluid administration

In the terminal stage of chronic renal failure, when the glomerular filtration rate is less than 10 ml/min (when the patient cannot excrete more than 1 liter of urine per day), fluid intake must be regulated according to diuresis (300-500 ml is added to the amount of urine excreted over the previous day).

2.4. Active methods of treating chronic renal failure

In the later stages of chronic renal failure, conservative treatment methods are ineffective, therefore, in the terminal stage of chronic renal failure, active treatment methods are carried out: continuous peritoneal dialysis, program hemodialysis, kidney transplantation.

2.4.1. Peritoneal dialysis

This method of treating patients with chronic renal failure consists of introducing into abdominal cavity a special dialysate solution into which, due to a concentration gradient, various substances contained in the blood and body fluids diffuse through the mesothelial cells of the peritoneum.

Peritoneal dialysis can be used both in the early stages of the terminal stage and in its final stages, when hemodialysis is not possible.

The mechanism of peritoneal dialysis is that the peritoneum plays the role of a dialysis membrane. The effectiveness of peritoneal dialysis is not lower than the effectiveness of hemodialysis. Unlike hemodialysis, peritoneal dialysis can also reduce the content of medium molecular weight peptides in the blood, since they diffuse through the peritoneum.

The technique of peritoneal dialysis is as follows. A lower laparotomy is performed and a Tenckhoff catheter is inserted. The end of the catheter, perforated for 7 cm, is placed in the pelvic cavity, the other end is removed from the anterior abdominal wall through the counter-aperture, and an adapter is inserted into the outer end of the catheter, which is connected to a container with a dialysate solution. For peritoneal dialysis, dialysate solutions are used, packaged in two-liter plastic bags and containing sodium, calcium, magnesium, lactate ions in percentages equal to their content in normal blood. The solution is changed 4 times a day - at 7, 13, 18, 24 hours. The technical simplicity of changing the solution allows patients to do it independently after 10-15 days of training. Patients easily tolerate the peritoneal dialysis procedure, they feel better quickly, and treatment can be carried out at home. A typical dialysate solution is prepared with a 1.5-4.35% glucose solution and contains sodium 132 mmol/L, chlorine 102 mmol/L, magnesium 0.75 mmol/L, calcium 1.75 mmol/L.

The effectiveness of peritoneal dialysis, carried out 3 times a week, lasting 9 hours, in terms of removal of urea, creatinine, correction of electrolyte and acid-base status, is comparable to hemodialysis, carried out three times a week for 5 hours.

There are no absolute contraindications to peritoneal dialysis. Relative contraindications: infection in the anterior abdominal wall, inability of patients to follow a diet high in protein (such a diet is necessary due to significant losses of albumin with the dialysate solution - up to 70 g per week).

2.4.2. Hemodialysis

Hemodialysis is the main method of treating patients with acute renal failure and chronic renal failure, based on the diffusion from the blood into the dialysate solution through a translucent membrane of urea, creatinine, uric acid, electrolytes and other substances retained in the blood during uremia. Hemodialysis is carried out using an “artificial kidney” apparatus, which consists of a hemodialyzer and a device with the help of which the dialysate solution is prepared and supplied to the hemodialyzer. In the hemodialyzer, the process of diffusion from the blood into the dialysate solution occurs various substances. The “artificial kidney” device can be individual for hemodialysis for one patient or multi-site, when the procedure is carried out simultaneously for 6-10 patients. Hemodialysis can be carried out in a hospital under the supervision of medical staff, in a hemodialysis center, or, as in some countries, at home (home hemodialysis). From an economic point of view, home hemodialysis is preferable; it also provides more complete social and psychological rehabilitation of the patient.

The dialysate solution is selected individually depending on the content of electrolytes in the patient’s blood. The main ingredients of the dialysate solution are as follows: sodium 130-132 mmol/l, potassium - 2.5-3 mmol/l, calcium - 1.75-1.87 mmol/l, chlorine - 1.3-1.5 mmol/l. No special addition of magnesium to the solution is required, because the level of magnesium in tap water is close to its content in the patient’s plasma.

To carry out hemodialysis over a significant period of time, constant reliable access to arterial and venous vessels is required. For this purpose, Scribner proposed an arteriovenous shunt - a method of connecting the radial artery and one of the veins of the forearm using Teflonosilastic. Before hemodialysis, the outer ends of the shunt are connected to the hemodialyzer. The Vreshia method has also been developed - the creation of a subcutaneous arteriovenous fistula.

A hemodialysis session usually lasts 5-6 hours and is repeated 2-3 times a week (programmed, permanent dialysis). Indications for more frequent hemodialysis arise when uremic intoxication increases. Using hemodialysis, you can extend the life of a patient with chronic renal failure by more than 15 years.

Chronic program hemodialysis is indicated for patients with end-stage chronic renal failure aged 5 (body weight more than 20 kg) to 50 years, suffering from chronic glomerulonephritis, primary chronic pyelonephritis, secondary pyelonephritis of dysplastic kidneys, congenital forms of ureterohydronephrosis without signs of active infection or massive bacteriuria, who agree to hemodialysis and subsequent kidney transplantation. Currently, hemodialysis is also performed for diabetic glomerulosclerosis.

Chronic hemodialysis sessions begin with the following clinical and laboratory indicators:

• glomerular filtration rate less than 5 ml/min;
• effective renal blood flow rate is less than 200 ml/min;
• urea content in blood plasma is more than 35 mmol/l;
• creatinine content in blood plasma more than 1 mmol/l;
• the content of “medium molecules” in the blood plasma is more than 1 unit;
• potassium content in blood plasma more than 6 mmol/l;
• decrease in standard blood bicarbonate below 20 mmol/l;
• deficiency of buffer bases more than 15 mmol/l;
• development of persistent oligoanuria (less than 500 ml per day);
• incipient pulmonary edema due to overhydration;
• fibrinous or less frequently exudative pericarditis;
• signs of increasing peripheral neuropathy.

Absolute contraindications to chronic hemodialysis are:

• cardiac decompensation with congestion in the systemic and pulmonary circulation, regardless of kidney disease;
• infectious diseases of any localization with an active inflammatory process;
• oncological diseases of any localization;
• tuberculosis of internal organs;
• gastrointestinal ulcer in the acute phase;
• severe liver damage;
• mental illness with a negative attitude towards hemodialysis;
• hemorrhagic syndrome of any origin;
• malignant arterial hypertension and its consequences.

During chronic hemodialysis, the diet of patients should contain 0.8-1 g of protein per 1 kg of body weight, 1.5 g of table salt, no more than 2.5 g of potassium per day.

With chronic hemodialysis it is possible the following complications: progression of uremic osteodystrophy, episodes of hypotension due to excessive ultrafiltration, infection viral hepatitis, suppuration in the shunt area.

2.4.3. Kidney transplant

Kidney transplantation is the optimal method of treating chronic renal failure, which consists of replacing a kidney damaged by an irreversible pathological process with an unchanged kidney. The selection of a donor kidney is carried out according to the HLA antigen system; most often, a kidney is taken from identical twins, the patient’s parents, and in some cases from people who died in a disaster and are compatible with the patient according to the HLA system.

Indications for kidney transplantation: I and II periods of the terminal phase of chronic renal failure. Kidney transplantation is not advisable for people over 45 years of age, as well as for patients with diabetes mellitus, since they have reduced kidney transplant survival.

The use of active treatment methods - hemodialysis, peritoneal dialysis, kidney transplantation - has improved the prognosis for terminal chronic renal failure and extended the life of patients by 10-12 and even 20 years.

Modern medicine manages to cope with most acute kidney diseases and curb the progression of most chronic ones. Unfortunately, until now, about 40% of renal pathologies are complicated by the development of chronic renal failure (CRF).

This term means the death or replacement by connective tissue of part of the structural units of the kidneys (nephrons) and irreversible impairment of the kidneys’ functions to cleanse the blood of nitrogenous waste, produce erythropoietin, which is responsible for the formation of red blood elements, remove excess water and salts, and reabsorb electrolytes.

The consequence of chronic renal failure is a disorder of water, electrolyte, nitrogen, acid-base balance, which entails irreversible changes in the state of health and often becomes the cause of death in terminal chronic renal failure. The diagnosis is made when disorders are registered for three months or longer.

Today, CKD is also called chronic kidney disease (CKD). This term emphasizes the potential for development severe forms renal failure even at the initial stages of the process, when the glomerular filtration rate (GFR) has not yet been reduced. This allows for more careful attention to patients with asymptomatic forms of renal failure and improves their prognosis.

Criteria for chronic renal failure

The diagnosis of chronic renal failure is made if the patient has one of two types of renal disorders for 3 months or more:

• Damage to the kidneys with disruption of their structure and function, which are determined by laboratory or instrumental methods diagnostics In this case, GFR may decrease or remain normal.
• There is a decrease in GFR of less than 60 ml per minute in combination with or without kidney damage. This rate of filtration corresponds to the death of about half of the nephrons of the kidneys.

What leads to chronic renal failure

Almost any chronic kidney disease without treatment can sooner or later lead to nephrosclerosis with the failure of the kidneys to function normally. That is, without timely therapy, such an outcome of any kidney disease, as chronic renal failure is just a matter of time. However, cardiovascular pathologies, endocrine diseases, systemic diseases may lead to renal failure.

• Kidney diseases: chronic glomerulonephritis, chronic tubulointerstitial nephritis, renal tuberculosis, hydronephrosis, polycystic kidney disease, nephrolithiasis.
• Pathologies of the urinary tract: urolithiasis, urethral strictures.
• Cardiovascular diseases: arterial hypertension, atherosclerosis, incl. angiosclerosis of the renal vessels.
• Endocrine pathologies: diabetes.
• Systemic diseases: renal amyloidosis, .

How does chronic renal failure develop?

The process of replacing the affected glomeruli of the kidney with scar tissue is simultaneously accompanied by functional compensatory changes in the remaining ones. Therefore, chronic renal failure develops gradually, passing through several stages in its course. The main reason for pathological changes in the body is a decrease in the rate of blood filtration in the glomerulus. The normal glomerular filtration rate is 100-120 ml per minute. An indirect indicator by which one can judge GFR is blood creatinine.

• The first stage of chronic renal failure is initial

At the same time, the glomerular filtration rate remains at the level of 90 ml per minute (normal variant). There is confirmed kidney damage.

• Second stage

It suggests kidney damage with a slight decrease in GFR in the range of 89-60. For older people, in the absence of structural damage to the kidneys, such indicators are considered normal.

• Third stage

In the third moderate stage, GFR drops to 60-30 ml per minute. At the same time, the process occurring in the kidneys is often hidden from view. There is no bright clinic. There may be an increase in the volume of urine excreted, a moderate decrease in the number of red blood cells and hemoglobin (anemia) and associated weakness, lethargy, decreased performance, pale skin and mucous membranes, brittle nails, hair loss, dry skin, decreased appetite. About half of the patients experience an increase in blood pressure (mainly diastolic, i.e. lower).

• Fourth stage

It is called conservative because it can be controlled by medications and, like the first, does not require blood purification using hardware methods (hemodialysis). At the same time, glomerular filtration is maintained at a level of 15-29 ml per minute. Clinical signs of renal failure appear: severe weakness, decreased ability to work due to anemia. The volume of urine excreted increases, significant urination at night with frequent urges at night (nocturia). Approximately half of patients suffer from high blood pressure.

• Fifth stage

The fifth stage of renal failure is called terminal, i.e. final. When glomerular filtration decreases below 15 ml per minute, the amount of urine excreted drops (oliguria) until it is completely absent in the outcome of the condition (anuria). All signs of poisoning of the body with nitrogenous wastes (uremia) appear against the background of water-electrolyte imbalance, damage to all organs and systems (primarily the nervous system, heart muscle). With this development of events, the patient’s life directly depends on blood dialysis (cleaning it bypassing non-functioning kidneys). Without hemodialysis or kidney transplantation, patients die.

Symptoms of chronic renal failure

Appearance of patients

The appearance does not suffer until the stage when glomerular filtration is significantly reduced.

• Pallor appears due to anemia, due to water and electrolyte disturbances dry skin.
• As the process progresses, yellowness of the skin and mucous membranes appears and their elasticity decreases.
• Spontaneous bleeding and bruising may occur.
• This causes scratching.
• Characterized by so-called renal edema with puffiness of the face, up to the common type of anasarca.
• The muscles also lose tone and become flabby, which causes fatigue to increase and the ability of patients to work decreases.

Nervous system lesions

This is manifested by apathy, night sleep disorders and daytime sleepiness. Decreased memory and learning ability. As chronic renal failure increases, severe inhibition and disturbances in the ability to remember and think appear.

Disturbances in the peripheral part of the nervous system affect the limbs with chilliness, tingling sensations, and crawling sensations. Later, movement disorders in the arms and legs develop.

Urinary function

She first suffers from polyuria (increased urine volume) with a predominance of nighttime urination. Further, chronic renal failure develops along the path of a decrease in urine volume and the development of edematous syndrome until the complete absence of excretion.

Water-salt balance

• salt imbalance manifests itself as increased thirst, dry mouth
• weakness, darkening of the eyes when standing up suddenly (due to sodium loss)
• Excess potassium may cause muscle paralysis
• breathing problems
• slowing of heartbeats, arrhythmias, intracardiac blockades up to cardiac arrest.

Against the backdrop of increased production parathyroid glands parathyroid hormone appears high levels of phosphorus and low level calcium in the blood. This leads to softening of the bones, spontaneous fractures, and itchy skin.

Nitrogen balance disorders

They cause an increase in blood creatinine, uric acid and urea, resulting in:

• when GFR is less than 40 ml per minute, enterocolitis develops (damage to the small and large intestines with pain, bloating, frequent loose stools)
• ammonia odor from the mouth
• secondary articular lesions such as gout.

The cardiovascular system

• firstly, it responds by increasing blood pressure
• secondly, damage to the heart (muscles - pericarditis, pericarditis)
• appear dull pain in the heart, disorders heart rate, shortness of breath, swelling in the legs, enlarged liver.
• If myocarditis progresses unfavorably, the patient may die due to acute heart failure.
• pericarditis can occur with the accumulation of fluid in the pericardial sac or the loss of uric acid crystals in it, which, in addition to pain and expansion of the borders of the heart, when listening to the chest, gives a characteristic (“funeral”) pericardial friction noise.

Hematopoiesis

Against the background of a deficiency in the production of erythropoietin by the kidneys, hematopoiesis slows down. The result is anemia, which manifests itself very early in weakness, lethargy, and decreased performance.

Pulmonary complications

characteristic of late stages CRF. This uremic lung - interstitial edema and bacterial inflammation lung against the background of a decrease in immune defense.

Digestive system

She reacts with decreased appetite, nausea, vomiting, inflammation of the oral mucosa and salivary glands. With uremia, erosive and ulcerative defects of the stomach and intestines appear, fraught with bleeding. Acute hepatitis is a frequent accompaniment of uremia.

Kidney failure during pregnancy

Even a physiologically occurring pregnancy significantly increases the load on the kidneys. In chronic kidney disease, pregnancy aggravates the course of the pathology and can contribute to its rapid progression. This is due to the fact that:

• During pregnancy, increased renal blood flow stimulates overexertion renal glomeruli and the death of some of them,
• deterioration of conditions for reabsorption of salts in the renal tubules leads to losses of high volumes of protein, which is toxic to renal tissue,
• increased functioning of the blood coagulation system contributes to the formation of small blood clots in the capillaries of the kidneys,
• worsening arterial hypertension during pregnancy contributes to glomerular necrosis.

The worse the filtration in the kidneys and the higher the creatinine numbers, the more unfavorable the conditions for pregnancy and its gestation. A pregnant woman with chronic renal failure and her fetus face a number of pregnancy complications:

• Arterial hypertension
• Nephrotic syndrome with edema
• Preeclampsia and eclampsia
• Severe anemia
• and fetal hypoxia
• Delays and malformations of the fetus
• and premature birth
• Infectious diseases of the urinary system of a pregnant woman

To resolve the issue of the advisability of pregnancy for each specific patient with chronic renal failure, nephrologists and obstetricians-gynecologists are involved. In this case, it is necessary to assess the risks for the patient and the fetus and correlate them with the risks that the progression of chronic renal failure every year reduces the likelihood of a new pregnancy and its successful resolution.

Treatment methods

The beginning of the fight against chronic renal failure is always the regulation of diet and water-salt balance

• Patients are recommended to eat a diet with limited protein intake to within 60 grams per day, with primary consumption vegetable proteins. As chronic renal failure progresses to stage 3-5, protein is limited to 40-30 g per day. At the same time, the share of animal proteins is slightly increased, giving preference to beef, eggs and lean fish. The egg-potato diet is popular.
• At the same time, the consumption of foods containing phosphorus (legumes, mushrooms, milk, white bread, nuts, cocoa, rice) is limited.
• Excess potassium requires reducing the consumption of black bread, potatoes, bananas, dates, raisins, parsley, figs).
• The sick have to make do drinking regime at a level of 2-2.5 liters per day (including soup and taking pills) in the presence of severe edema or intractable arterial hypertension.
• It is useful to keep a food diary, which makes it easier to track the protein and microelements in food.
• Sometimes specialized mixtures, enriched with fats and containing a fixed amount of soy proteins and balanced in microelements, are introduced into the diet.
• Along with the diet, patients may be prescribed an amino acid substitute - Ketosteril, which is usually added when GFR is less than 25 ml per minute.
• A low-protein diet is not indicated for exhaustion, infectious complications of chronic renal failure, uncontrolled arterial hypertension, with GFR less than 5 ml per minute, increased protein breakdown, after surgery, severe nephrotic syndrome, terminal uremia with damage to the heart and nervous system, and poor diet tolerance.
• Salt is not limited to patients without severe arterial hypertension and edema. In the presence of these syndromes, salt is limited to 3-5 grams per day.

Enterosorbents

They can somewhat reduce the severity of uremia by binding in the intestines and removing nitrogenous wastes. This works in the early stages of chronic renal failure with relative preservation of glomerular filtration. Polyphepan, Enterodes, Enterosgel, Activated carbon, are used.

Treatment of anemia

To relieve anemia, Erythropoietin is administered, which stimulates the production of red blood cells. Uncontrolled arterial hypertension becomes a limitation to its use. Since iron deficiency may occur during treatment with erythropoietin (especially in menstruating women), therapy is supplemented oral medications iron (Sorbifer durules, Maltofer, etc., see).

Bleeding disorder

Correction of blood clotting disorders is carried out with Clopidogrel. Ticlopedin, Aspirin.

Treatment of arterial hypertension

Drugs for the treatment of arterial hypertension: ACE inhibitors (Ramipril, Enalapril, Lisinopril) and sartans (Valsartan, Candesartan, Losartan, Eprosartan, Telmisartan), as well as Moxonidine, Felodipine, Diltiazem. in combinations with saluretics (Indapamide, Arifon, Furosemide, Bumetanide).

Phosphorus and calcium metabolism disorders

It is stopped with calcium carbonate, which prevents the absorption of phosphorus. Lack of calcium – synthetic drugs vitamin D.

Correction of water and electrolyte disorders

is carried out in the same way as the treatment of acute renal failure. The main thing is to relieve the patient from dehydration due to restrictions in the diet of water and sodium, as well as eliminating blood acidification, which is fraught with severe shortness of breath and weakness. Solutions with bicarbonates and citrates, sodium bicarbonate are introduced. A 5% glucose solution and Trisamine are also used.

Secondary infections in chronic renal failure

This requires the prescription of antibiotics, antiviral or antifungal drugs.

Hemodialysis

With a critical decrease in glomerular filtration, blood purification from substances of nitrogen metabolism is carried out by hemodialysis, when waste products pass into the dialysis solution through a membrane. The most commonly used device is an “artificial kidney”; less commonly, peritoneal dialysis is performed, when the solution is poured into the abdominal cavity, and the peritoneum plays the role of a membrane. Hemodialysis for chronic renal failure is carried out in a chronic mode. For this, patients travel several hours a day to specialized Center or hospital. In this case, it is important to prepare an arteriovenous shunt in a timely manner, which is prepared at a GFR of 30-15 ml per minute. From the moment the GFR drops to less than 15 ml, dialysis begins in children and patients with diabetes mellitus; when the GFR falls below 10 ml per minute, dialysis is carried out in other patients. In addition, indications for hemodialysis will be:

• Severe intoxication with nitrogenous products: nausea, vomiting, enterocolitis, unstable blood pressure.
• Treatment-resistant edema and electrolyte disturbances. Cerebral edema or pulmonary edema.
• Severe blood acidification.

Contraindications to hemodialysis:

• bleeding disorders
• persistent severe hypotension
• tumors with metastases
• decompensation of cardiovascular diseases
• active infectious inflammation
• mental illness.

Kidney transplant

This is a radical solution to the problem of chronic kidney disease. After this, the patient has to use cytostatics and hormones for life. There are cases of repeated transplants if for some reason the graft is rejected. Renal failure during pregnancy with a transplanted kidney is not an indication for termination of pregnancy. pregnancy can be carried to the required term and is usually resolved by cesarean section at 35-37 weeks.

Thus, Chronic kidney disease, which has replaced the concept of “chronic renal failure” today, allows doctors to see the problem more timely (often when external symptoms not yet present) and respond by starting therapy. Adequate treatment can prolong or even save the patient’s life, improve his prognosis and quality of life.