Internal illnesses. Chronic renal failure (lecture notes)

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Internal illnesses. Chronic renal failure (lecture notes)

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LECTURE No. 40. Chronic renal failure

Chronic renal failure is a gradually occurring and steadily progressive impairment of kidney function, leading to uremic intoxication.

Etiology. Etiological factors are: chronic glomerulonephritis, chronic pyelonephritis, diabetic glomerulonephritis, amyloidosis, polycystic kidney disease, nephrolithiasis, adenoma, prostate cancer.

Pathogenesis. Pathogenetic mechanisms of the disease: lack of parenchyma regeneration, inevitable structural changes in the parenchyma, a decrease in the number of functioning nephrons, their atrophy and shrinkage, impaired excretory, blood-purifying and homeostatic functions, retention of nitrogenous metabolic products in the blood: urea, uric acid, ammonia, amino acids, creatinine, guanidine, phosphate retention, increased plasma and extracellular fluid potassium levels, hypocalcemia.

Classification. The composition of chronic renal failure includes: chronic uremia, diffuse sclerosing glomerulonephritis, end-stage kidney disease, and other manifestations of chronic renal failure.

Table 5. Stages of chronic renal failure (according to Shulutko B.I., 1994)

Clinic. When subclinical form there is an increase in the amount of fluid you drink (up to 3 liters per day), nocturia (up to 3 times per night), dryness, flabbiness of the skin, its peeling, daytime sleepiness, weakness, fatigue, tinnitus, hearing loss.

RџSЂRё clinical form there are signs of pulmonary heart failure, severe anemia, changes in the liver, gastrointestinal tract without impaired function.

RџSЂRё terminal form intoxication is expressed: slowness, lethargy, drowsiness, puffy face, dry skin, excruciating itching, no sweating, muscle weakness, muscle twitching, large convulsions (due to a decrease in calcium in the blood), deep noisy breathing, chest pain, development of secondary pneumonia, wet wheezing, in the terminal stage - uremic pulmonary edema. Uremic pericarditis develops (auscultatively: pericardial friction rub), hypertensive cardiovascular syndrome, uremic vasculitis, visceritis, hypothermia. Appears anorexia, aversion to food, nausea, vomiting, heaviness, fullness in the epigastrium after eating, thirst. Anemia, toxic leukocytosis with a neutrophilic shift to the left, thrombocytopenia, and a violation of blood coagulation develop. There is damage to the bones, a change in the skeleton, secondary gout, a change in polyuria to oligo- and anuria, the urinary syndrome is slightly expressed.

Additional diagnostic study. A study of blood serum creatinine, a study of nitrogenous metabolic products (residual nitrogen, urea, uric acid), a study of the state of electrolyte and mineral metabolism, an acid-base state, an ultrasound examination of the kidneys, an ECG study are carried out.

Treatment. Patients are shown a diet (physiological, complete) to prevent the breakdown of their own protein, possibly in combination with parenteral administration of anabolic hormones (retabolil 50 mg intramuscularly 1 time in 10-15 days), an extended drinking regimen.

Elimination of hyperkalemia: the introduction of large amounts of glucose 40% - 100 or 200 ml with the addition of 15-20 units of insulin, 10% calcium chloride solution, 3-5% sodium bicarbonate solution (increase in blood potassium levels up to 7 g / day is an absolute indicator for connection to an artificial kidney).

Elimination of hyponatremia: intravenous administration of 10% sodium chloride solution.

Elimination of hypernatremia: the introduction of natridiuretics (10% calcium gluconate solution), tachystin (0,125 mg).

Elimination of acidosis: diet, soda enemas, intravenous administration of alkaline solutions.

Elimination of alkalosis: ammonium or 200 ml of 2% potassium chloride solution;

Elimination of anemia: testosterone 300 mg per week for 3-6 months or sustanon 1 ml intramuscularly 1 time per week; iron preparations only in case of their deficiency, the amino acid histidine, blood transfusion only in case of acute blood loss and hemoglobin level below 60-70 g/l.

Hemodialysis is carried out: hydrocarbonate on capillary dialyzers based on highly permeable cellulose acetate membranes 3-5 times a week for 5 hours. diseases, hemorrhagic syndrome): dialysis fluid is introduced into the peritoneal cavity in small portions for a certain time, and then replaced with a fresh solution. Hemosorption is used: removal of toxic substances from the blood when it passes through a column with activated carbon, the content of toxic substances decreases markedly after 60 hours from the start of the procedure.

To reduce renal hypertension, all antihypertensive drugs are used, a decrease in pressure to normal values is not shown: only to a working level to prevent a decrease in filtration function.

To reduce the edematous syndrome, thiazide derivatives, furosemide with a possible combination with triamterene, veroshpiron are prescribed in the absence of hyperkalemia.

They use herbal preparations (lespenephril (despidoza drug)), kidney transplantation.

Forecast. The prognosis is determined by the phase of renal failure, the rate of its development.

Prevention. Preventive measures: active treatment of underlying diseases, systematic planned secondary prevention of chronic renal failure, clinical examination.

Author: Myshkina A.A.

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