Pathology of chronic kidney failure

2021-01-26 12:00 AM

According to French statistics, among 70 new patients with end-stage chronic kidney failure, only 5 patients are children and adolescents.

Outline

Chronic renal failure is the result of chronic kidney disease that causes a gradual decrease in the number of functional nephrons that gradually decrease the glomerular filtration rate.

When the glomerular filtration rate drops below 50% (60ml / min) of the normal level (120ml / min), chronic kidney failure is considered.

Chronic kidney failure is a syndrome that progresses in stages: in the early stage, there are only a few very discreet symptoms in the clinic, whereas in the late stage, there is a strong manifestation of hyperuricemia syndrome. The course of chronic kidney failure can last from months to years.

Epidemiology

Determining the incidence and chronic kidney failure is a difficult problem because, in early-stage chronic kidney failure, patients often see fewer doctors because of little or no clinical symptoms. Less well-known pre-end chronic renal failure is due to the absence of registration and follow-up, but the incidence of end-stage chronic renal failure requiring treatment for renal failure is a known way. exactly. According to statistics in France, the incidence of end-stage chronic kidney failure is 120 cases / 1 million people/year. In the US and Japan, there are 300 cases / 1 million people/year (data for 2003).

The incidence of chronic kidney failure tends to increase over time and varies from country to country.

Chronic kidney failure is a medical condition that occurs primarily in adults. According to French statistics, among 70 new patients with end-stage chronic kidney failure, only 5 patients are children and adolescents, and 65 patients are adults. Chronic kidney failure is also related to sex, with men twice as sick as women (2/1). The average age of new patients starting treatment for end-stage renal failure gradually increased: in 1987 it was 55 years old, in 1998 it was 61 years old.

Reason

Most chronic kidney disease, whether the onset is glomerulonephropathy, renal tubular disease or renal vascular disease, can lead to chronic renal failure.

Chronic glomerulonephritis

Most common, accounting for 40%.

Chronic glomerulonephritis here can be primary or secondary after systemic diseases such as systemic lupus erythematosus, diabetes mellitus, and rheumatoid purpura.

Chronic pyelonephritis

Accounting for about 30%.

Note: Chronic pyelonephritis in patients with urinary kidney stones is a common cause in Vietnam.

Interstitial nephritis

Usually due to long-term use of pain relievers such as Phenylbutazone, due to hyperuricemia, hypercalcemia.

Kidney vascular disease

Benign or malignant renal artery.

Renal microvascular thrombosis.

Inflammation around the nodular artery.

Renal venous obstruction.

Congenital kidney disease is inherited or not inherited

Polycystic kidney.

Kidney dysplasia.

Alport syndrome.

Metabolic kidney disease (Cystinose, Oxalose).

Systemic, metabolic disease

Diabetes.

Colloid pathology: Lupus.

Currently, the main causes of chronic kidney failure in the developed world are mainly renal vascular and metabolic diseases (diabetes mellitus, renal vascular disease) while in developing countries the group of causes is caused by bacteria, Urinary kidney stones still account for a high proportion

Mechanism of pathogenesis

The pathogenesis of chronic renal failure is explained on the basis of the theory of intact nephron: Although the lesions are initiated in the glomeruli, renal blood vessels, renal interstitial tubular organization, the severely damaged nephrons are also common. excluded from a functional physiological role. The function of the kidney is only performed by the remaining intact nephrons, when the remaining intact nephrons are not enough to ensure that the kidney's function of maintaining the homeostasis will occur. about water electrolytes, circulatory, respiratory, digestive, nerve causes chronic kidney failure syndrome.

Clinical

Whew

Depending on the cause of chronic kidney failure, the patient may have a lot of oedemata, little or no oedema. Chronic renal failure due to pyelonephritis is usually not oedematous in the early stage, the only oedema in the late stage. While chronic renal failure due to oedema glomerulonephritis is a common symptom. Whatever the cause, in end-stage chronic kidney failure, oedema is a constant symptom.

Anaemia

Usually severe or mild depending on the stage, the more severe the kidney failure, the greater the anaemia.

This is an important symptom to differentiate from acute kidney failure.

Hypertension

About 80% of patients with chronic renal failure have hypertension.

Heart failure

When heart failure occurs, it means that chronic kidney failure is late, heart failure is caused by salt retention, water retention, long-term hypertension and anaemia.

Digestive disorders

In the early stage is usually anorexia, in stage III onwards there is nausea, diarrhoea, sometimes gastrointestinal bleeding.

Haemorrhage

Nose, root, or subcutaneous bleeding is common. If there is gastrointestinal bleeding, it is very heavy, making blood urea, blood potassium increase rapidly.

Pericarditis

As a manifestation in the late stages of chronic kidney failure with the classic symptom of pericardial scrubbing, this is a sign of death if not receiving dialysis treatment promptly.

Itching

It is the skin manifestation seen in chronic renal failure in the stage of secondary hyperparathyroidism with the deposition of calcium in the subcutaneous organization.

Cramp

Usually occurs at night, maybe due to decreased sodium, hypocalcaemia.

Comatose

Lethargy due to high blood urea is a clinical manifestation in the late stage of chronic renal failure. Patients may have seizures, psychosis in pre-coma. The characteristic of chronic hyperaemia coma is the absence of focal neurological symptoms.

The above are general clinical manifestations of chronic renal failure. In addition, depending on the cause of chronic renal failure in each patient, there are corresponding symptoms such as large kidney in polycystic kidney disease, kidney fluid retention, ...

Subclinical

Increased blood urea, blood creatinine.

Decreased coefficient of creatinine clearance.

Blood Potassium: Blood potassium may be normal or decreased. When blood potassium is high, there is an exacerbation with oliguria or anuria.

Blood calcium, blood phosphorus: in the first stage blood calcium decreases, blood phosphorus increases. In the period of secondary hyperthyroidism, both serum calcium and phosphorus are increased.

Proteinuria: depending on the cause, when kidney failure stage III, IV, there is always proteinuria but not high.

Red blood cells, white blood cells: depending on the cause of chronic kidney failure.

Implementing the quadrants

Signs of kidney failure

Increased urea, blood creatinine.

The level of glomerular filtration decreased.

Chronic nature of the renal failure

The criterion of history: History of kidney disease, prior hyperchloremia.

Morphological criteria: decreased kidney size (height <10cm on ultrasound, <3 vertebrae on unprepared kidney scan).

Biological Criteria: There are 2 abnormalities leading to chronic renal failure:

Anaemia with normal erythrocytes is not deformed.

Lower blood calcium.

Stage diagnosis

Based on the coefficients of creatinine, serum creatinine: chronic renal failure is divided into the following stages:

Stage

 

chronic renal failure

 

HSTT creatinine (ml / min)

Creatinine blood

micromole / l

mg / dl

Normal

120

70-106

0,8 - 1,2

I

60-41

< 130

< 1,5

II

40-21

130 - 299

1,5 - 3,4

IIIa

20-11

300-499

3,5 - 5,9

IIIb

10-5

500-900

6,0 - 10

IV

<5

> 900

> 10

Diagnose the cause

Finding the causes of chronic kidney failure has important implications for diagnosis. When the cause is ruled out, chronic renal failure, although irreversible, may delay the progression of chronic kidney failure.

Causes of chronic kidney failure include chronic glomerulonephritis, chronic pyelonephritis, renal vascular disease, congenital and genetic kidney disease.

Differential diagnosis

Acute Renal Failure: Based on History - Causes - Progression of Kidney Failure.

Exacerbation of chronic renal failure: based on history, blood urea/creatinine ratio (μmol / l)> 100.

Complications diagnosis

Pay attention to complications on cardiovascular, blood, digestive, nervous, infection, water-electrolyte disorders, acidosis ...

Diagnosis of aggravating factors of renal failure

Hypertension.

Bacterial infections, gastrointestinal bleeding, dehydration.

Urinary tract obstruction.

Use nephrotoxic drugs.

Eating too much protein.

Treatment

Depending on the stage of chronic kidney failure, treatment may vary. Moreover, it also depends on economic and social factors, especially the replacement treatment of kidney failure.

Treatment of chronic kidney failure before the last stage

Corresponding to the treatment of chronic kidney failure stages I, II and IIIa, when glomerular clearance is more than 10 ml/min. These measures preserve residual kidney function

General principles:

When the patient has chronic kidney disease, even without renal failure or mild renal failure, it must be monitored by a kidney specialist to detect and treat the cause of severe, systematic monitoring. The patient's system depends on the severity of chronic kidney failure.

Purpose of disease monitoring.

Monitor treatment for kidney disease.

Prevent the progression of chronic kidney failure.

Avoid nephrotoxic drugs and adjust the dose accordingly to the degree of renal failure.

Treatment of complications of chronic renal failure, cardiovascular risk factors, especially hypertension and associated factors.

Inform patients about treatment strategies depending on the patient and the stage of renal failure.

Preparing for the replacement treatment of kidney failure in the last stage: Hepatitis B vaccination, in stage IIIa can connect the catheter - vein.

Slows the progression of chronic kidney failure.

Good treatment of the cause of chronic kidney failure.

Well maintain blood pressure and reduce Proteinuria:

This is a very important point in the treatment of mild stage chronic renal failure.

In these patients, the optimal blood pressure to be achieved will depend on the amount of proteinuria:

If chronic renal failure has proteinuria <1g / 24 hours, the optimal blood pressure will be ≤ 130/80 mmHg.

If CKD has Proteinuria ≥ 1g / 24 hours and/or Diabetes, the optimal blood pressure will be ≤ 125/75 mmHg.

Provide protein in the right diet:

In the case of mild, moderate renal impairment (ClCr 30 to 60 ml/min) Protide can be given in a dose of 1g / kg/day. In case of more severe renal failure, protein supply from 0.6 to 0.8 g / kg/day.

Avoid nephrotoxic drugs and change the dose accordingly according to the degree of renal failure.

Treatment of complications of chronic kidney failure.

Cardiovascular risk factors:

Hypertension: Good maintenance of blood pressure will reduce cardiovascular morbidity and mortality in patients with chronic renal failure.

Treatment of dyslipidaemia:

Use the Statin group mainly when increasing blood cholesterol.

Fibrate group in case of increased Triglycerides.

Eliminate other risk factors:

Quit smoking.

Good treatment of diabetes.

Weight loss in obese patients.

Treatment of calcium-phosphorus balance disorders:

Maintain normal blood calcium concentration.

The phosphorus of blood is less than 1.5 mmol / l.

PTH blood is less than 3 times normal.

Adjust the acid-base balance:

Sodium Bicarbonate sodium salt is often used orally or by infusion depending on the mild or severe disorder.

Treatment of hyperaemia Uric acidosis:

Attack with Colchicine.

Prevent recurrence with Allopurinol.

Treatment of anaemia:

The aim of treatment is to maintain blood Hb at 11 to 12 g / l.

Treatment of electrolyte water disorders:

Bland diet: is used in most kidney diseases.

Reduce water intake in case of oedema.

Treatment of Hyperkalaemia

Treatment of end-stage chronic kidney failure

When the glomerular filtration rate drops below 10 ml/min, in addition to the methods of conservative treatment as above, to ensure the patient's survival, it is necessary to have alternative treatments for kidney failure, including:

Kidney transplant.

Artificial kidney.

Peritoneal dialysis.

Preventive

Primary prophylaxis: Eliminate the risk factors leading to kidney and urinary problems such as personal regimen, hygiene, eating, and use of nephrotoxic drugs.

Grade 2 prophylaxis: Early detection of kidney and urinary diseases by clinical examination, proteinuria, and thorough treatment of urinary kidney disease.

Prophylaxis of grade 3: In the presence of chronic renal failure. This prophylaxis includes specific measures: determining the cause, effective treatment to rule out the underlying cause of chronic renal failure, or nonspecific measures: eliminating progression factors. Rapid aggravation of kidney failure.