Chronic renal failure
Chronic renal failure – the gradual fading of kidney functions caused by death of nefron owing to a chronic disease of kidneys. Gradual deterioration in function of kidneys leads to violation of activity of an organism, emergence of complications from various bodies and systems. Allocate the latent, compensated, intermittiruyushchy and terminal stages of HPN. Diagnostics of patients with a chronic renal failure includes clinical and biochemical analyses, Reberg and Zimnitsky's tests, ultrasonography of kidneys, UZDG of kidney vessels. Treatment of HPN is based on therapy of the main disease, symptomatic treatment and repeated courses of extracorporal haemo correction.
Chronic renal failure
The Chronic Renal Failure (CRF) – irreversible violation of filtrational and secretory functions of kidneys, up to their complete cessation, owing to death of renal fabric. HPN has the progressing current, at early stages is shown by a general malaise. At increase of HPN – the expressed organism intoxication symptoms: weakness, appetite loss, nausea, vomiting, hypostases, integuments - dry, pale yellow. Sharply, sometimes to zero, the diuresis decreases. At late stages heart failure, tendency to bleedings, hypostasis of lungs, encephalopathy, an uraemic coma develops. The hemodialysis and renal transplantation are shown.
The chronic renal failure can become an outcome of a chronic glomerulonefrit, nephrites at system diseases, hereditary nephrites, chronic pyelonephritis, a diabetic glomeruloskleroz, amiloidoz of kidneys, a polikistoz of kidneys, a nefroangioskleroz and other diseases which affect both kidneys or the only kidney.
The progressing death of nefron is the cornerstone of pathogenesis. In the beginning kidney processes become less effective, then function of kidneys is broken. The morphological picture is defined by the main disease. The histologic research demonstrates death of a parenchyma which is replaced with connecting fabric.
Development in the patient of a chronic renal failure is preceded by the suffering period a chronic disease of kidneys lasting from 2 to 10 and more years. The course of disease of kidneys prior to development of HPN can be subdivided into a number of stages conditionally. Definition of these stages is of practical interest as influences the choice of tactics of treatment.
Classification of HPN
Allocate the following stages of a chronic renal failure:
- Latent. Proceeds without the expressed symptoms. Usually comes to light only by results of in-depth clinical trials. The glomerular filtration is lowered to 50-60 ml/min., the periodic proteinuria is noted.
- Compensated. The patient is disturbed by increased fatigue, feeling of dryness in a mouth. Increase in volume of urine at decrease in its relative density. Decrease in a glomerular filtration to 49-30 ml/min. Level of creatinine and urea is increased.
- Intermittiruyushchy. Expressiveness of clinical symptoms amplifies. There are complications caused by the accruing HPN. The condition of the patient changes wavy. Decrease in a glomerular filtration to 29-15 ml/min., acidosis, permanent increase in level of creatinine.
- Terminal. It is subdivided into four periods:
- I. A diuresis more than one liter a day. Glomerular filtration of 14-10 ml/min.;
- IIA. The volume of the emitted urine decreases to 500 ml, the gipernatriyemiya and a giperkaltsiyemiya, increase of signs of a delay of liquid, dekompensirovanny acidosis is noted;
- IIB. Symptoms become more expressed, the phenomena of heart failure, developments of stagnation in a liver and lungs are characteristic;
- III. The expressed uraemic intoxication, a giperkaliyemiya, a gipermagniyemiya, a gipokhloremiya, a giponatriyemiya, the progressing heart failure develops, poliserozit, liver dystrophy.
Defeat of bodies and systems at HPN
- Blood changes: anemia at a chronic renal failure is caused by both blood formation oppression, and reduction of life of erythrocytes. Note coagulability violations: lengthening of time of bleeding, thrombocytopenia, reduction of quantity of a prothrombin.
- Complications from heart and lungs: arterial hypertension (more than at a half of patients), stagnant heart failure, perikardit, myocarditis. At late stages the uraemic pneumonitis develops.
- Neurologic changes: from TsNS at early stages - absent-mindedness and a sleep disorder, on late – block, confusion of consciousness, in certain cases nonsense and hallucinations. From peripheral nervous system – peripheral polyneuropathy.
- Violations from a GIT: at early stages – deterioration in appetite, dryness in a mouth. There is an eructation, nausea, vomiting, stomatitis later. As a result of irritation mucous at allocation of products of metabolism develops enterokolit also atrophic gastritis. The superficial stomach ulcers and intestines which are quite often becoming bleeding sources are formed.
- Violations from the musculoskeletal device: various forms of osteodystrophy are characteristic of HPN (osteoporosis, an osteosclerosis, an osteomalyation, fibrous osteit). Clinical displays of osteodystrophy – spontaneous fractures, deformations of a skeleton, a sdavleniye of vertebras, arthritises, bone and muscles pains.
- Violations from immune system: at HPN the limfotsitopeniya develops. Decrease in immunity causes the high frequency of emergence is purulent - septic complications.
During the period preceding development of a chronic renal failure, kidney processes remain. Level of a glomerular filtration and kanaltsevy reabsorption is not broken. In the subsequent the glomerular filtration gradually decreases, kidneys lose ability to concentrate urine, kidney processes begin to suffer. At this stage the homeostasis is not broken yet. Further the quantity of the functioning nefron continues to decrease, and at decrease in a glomerular filtation to 50-60 ml/min. the patient has first signs of HPN.
Patients with a latent stage of HPN usually do not show complaints. In certain cases they note unsharply expressed weakness and decrease in working capacity. Patients with HPN in the compensated stage are disturbed by decrease in working capacity, increased fatigue, periodic feeling of dryness in a mouth. At an intermittiruyushchy stage of HPN symptoms become more expressed. Weakness increases, patients complain of constant thirst and dryness in a mouth. Appetite is reduced. Skin is pale, dry.
Patients with a terminal stage of HPN grow thin, their skin becomes gray-yellow, flabby. The skin itch, the lowered muscular tone, a tremor of brushes and fingers, small twitchings of muscles is characteristic. Thirst and dryness in a mouth amplifies. Patients are apathetic, sleepy, cannot concentrate.
At increase of intoxication the characteristic smell of ammonia from a mouth, nausea and vomiting appears. The periods of apathy are replaced by excitement, the patient is slowed down, inadequate. Dystrophy, a hypothermia, hoarseness of a voice, lack of appetite, aftozny stomatitis is characteristic. The stomach is blown up, frequent vomiting, a diarrhea. The chair is dark, fetid. Patients show complaints to a painful skin itch and frequent muscular twitchings. Anemia accrues, the hemorrhagic syndrome and renal osteodystrophy develops. Typical manifestations of HPN in a terminal stage are myocarditis, perikardit, encephalopathy, hypostasis of lungs, ascites, gastrointestinal bleedings, an uraemic coma.
Diagnostics of HPN
At suspicion on development of a chronic renal failure consultation of the nephrologist and carrying out laboratory researches is necessary for the patient: biochemical blood test and urine, Reberg's test. Decrease in level of a glomerular filtration, increase of level of creatinine and urea becomes the basis for diagnosis.
When conducting test of Zimnitsky the izogipostenuriya comes to light. Ultrasonography of kidneys demonstrates decrease in thickness of a parenchyma and reduction of the size of kidneys. Decrease in an intra organ and main kidney blood-groove comes to light on UZDG of vessels of kidneys. The X-ray contrast urography should be applied with care because of a nefrotoksichnost of many contrast agents.
Treatment of HPN
The modern urology has extensive opportunities in treatment of a chronic renal failure. The timely treatment directed to achievement of permanent remission quite often allows to slow down significantly development of HPN and to delay emergence of the expressed clinical symptoms. When performing therapy to the patient with an early stage of HPN special attention is paid to actions for prevention of progressing of the main disease.
Treatment of the main disease continues also at violation of kidney processes, but during this period value of symptomatic therapy increases. The special diet is necessary for the patient. If necessary appoint antibacterial and hypotensive medicines. Sanatorium treatment is shown. Control of level of a glomerular filtration, concentration function of kidneys, a kidney blood-groove, level of urea and creatinine is required.
At violations of a homeostasis correction of acid-base structure, an azotemiya and water-salt balance of blood is carried out. Symptomatic treatment consists in treatment of anemichesky, hemorrhagic and hypertensive syndromes, maintenance of normal warm activity.
The patient with a chronic renal failure appoints high-calorific (about 3000 calories) the reduced-protein diet including irreplaceable amino acids. It is necessary to reduce amount of salt (to 2-3 g/days), and at development of the expressed hypertension – to transfer the patient to a saltless diet.
Protein content in a diet depending on extent of violation of kidney functions:
- the glomerular filtration is lower than 50 ml/min. The amount of protein decreases to 30-40 g/days;
- the glomerular filtration is lower than 20 ml/min. The amount of protein decreases to 20-24 g/days.
At development of renal osteodystrophy appoint vitamin D and a gluconate of calcium. It is necessary to remember danger of the kaltsifikation of internals caused by high doses of vitamin D at a giperfosfatemiya. For elimination of a giperfosfatemiya appoint + aluminum hydroxide. During therapy the level of phosphorus and calcium in blood is controlled.
Correction of acid-base structure is carried out by 5% sodium hydrocarbonate solution intravenously. At an oliguriya for increase in volume of the emitted urine appoint furosemide in a dosage which provides a polyuria. To normalization HELL is applied by standard hypotensive medicines in combination with furosemide.
At anemia appoint iron medicines, androgens and folic acid, at decrease in a gematokrit to 25% carry out fractional transfusions of eritrotsitny weight. The dosage of chemotherapeutic medicines and antibiotics is defined depending on a way of removal. Doses of sulfanylamides, a tsefaloridina, a metitsillina, ampicillin and penicillin reduce by 2-3 times. At reception of a polimiksin, Neomycinum, monomitsin and streptomycin even in small doses development of complications is possible (neuritis of an acoustical nerve, etc.). Derivatives of nitrofurans are contraindicated to sick HPN.
It is necessary to use glycosides at therapy of heart failure with care. The dosage decreases, especially at development of a gipokaliyemiya. The patient with an intermittiruyushchy stage of HPN in the period of an aggravation appoint a hemodialysis. After improvement of a condition of the patient transfer to conservative treatment again. Purpose of repeated courses of a plasma exchange is effective.
At approach of a terminal stage and lack of effect of symptomatic therapy to the patient appoint a regular hemodialysis (2-3 times a week). Transfer to a hemodialysis is recommended at decrease in clearance of creatinine lower than 10 ml/min. and increase in its level in plasma to 0,1 g/l. Choosing therapy tactics, it is necessary to consider that development of complications at a chronic renal failure reduces effect of a hemodialysis and excludes a possibility of transplantation of a kidney.
Steady rehabilitation and essential extension of term of life it is possible at timely carrying out a hemodialysis or renal transplantation. The decision on a possibility of carrying out these types of treatment is made by transplantologists and doctors of the centers of a hemodialysis.