Take care of children with fatty kidney disease

2021-01-30 12:00 AM

High protein urination leads to a decrease in blood protein, and as this reduces the colloid pressure in the blood, resulting in water in the lumen escaping the intercellular causing less swelling and urination.

General perception

Null syndrome

Called nephrotic syndrome when the patient has:

Big oedema.

High proteinuria.

Blood protein is greatly reduced.

Lipids and high blood cholesterol

Fatty kidneys

Fatty nephrotic syndrome is a primary nephrotic syndrome with minimal damage to the basal membrane of the stem (in podocytes).

This is a chronic or recurrent, illness that usually lasts for many years, with no known cause, but can be cured.

Mechanism of pathogenesis

Fatty kidney disease is an autoimmune disease.

The main damage is podocyte cells that lose the leg or / and damage the nucleus.

When podocyte cells lose their legs, the holes in the lamina densa membrane expand, causing proteins with a molecular weight of more than 70,000 Daltons to fall into the Bowman’s cavity, leading to urination.

High-protein urination leads to a decrease in blood protein, and thus the colloid pressure in the blood will decrease, leading to water in the lumen escaping the intercellular causing less swelling and urination. Excessive drainage of the intercellular water can lead to the collapse of the mesenteric veins, causing severe abdominal pain.

Reduced blood protein, especially y-globulin (IgG) reduction, will be one of the causes leading to a decrease in the body's resistance, so it is easy to be susceptible to infectious complications, especially in the period of taking high doses of corticosteroids (because high doses of corticoids have immunosuppressive effects).

Normally, 85% of the calcium in the blood is bound to the protein. In fatty body disease, protein is lost a lot in the urine, causing the amount of calcium bound to protein in the blood to decrease; the Ca ++ / Ca ratio associated with protein is changed. When a patient eats a lot of fish meat, blood protein will increase, Ca ++ begins to bind to the newly created protein, causing the concentration of Ca ++ in the blood to decrease. A decrease in the concentration of Ca ++ in the blood will lead to an increase in neuromuscular stimulation that is clinically manifested as spasticity or contraction (tetani). This complication usually occurs during the period when the symptoms of oedema begin to decrease greatly and it is also when the protein in the blood is increasing. The process of protein binding Ca + is accelerated by the phenomenon of alkalosis of blood due to the loss of a lot of Potassium under the effect of Aldosterone, so K + goes out from the cell and H + from the outside into the cell.

Loss of lipoprotein-lipase, fatty acid albumin, cholesterol synthesis inhibitors, Thyroxin has resulted in increased cholesterol and lipids.

Through the pathogenesis mechanism, we not only know the reasons for the occurrence of clinical symptoms, laboratory changes but also help us to know the possible complications, the main stages. in the treatment, care and monitoring of patients.

Clinical signs

Whew

In fatty kidney, disease oedema is the most prominent and appears to be the earliest clinical signs. oedema properties in the fatty kidney are:

oedema appears suddenly in the morning after waking up.

oedema begins to appear on the eyelids, on the face and then appears on the legs, abdomen and body.

White oedema.

Soft oedema, concave.

Swollen and very large: chubby eyes, droopy cheeks, sagging chin, big belly, chubby limbs.

Often accompanied by effusion of peritoneum, testicular membranes. In the case of pleural effusion, clinical signs of shortness of breath are evident and accompanied by a decreased response (chiseliness, alveolar fencing decreased, vocal fibrillation decreased).

oedema progresses very quickly.

oedema decreases when using corticosteroids, protein infusions or eating a lot of protein-rich foods such as meat, eggs, fish, etc.

oedema in fatty kidney disease is the result of water flowing out from the capillary lumen to the intercellular space due to decreased colloid pressure in the blood.

Little urination, yellow urine

Less urination is a consequence of water retention in the intercellular space due to a decrease in the colloid pressure in the blood. Light yellow urine is because it is concentrated (normal or increased glomerular filtration rate than usual) and contains more protein.

Symptoms

Infection

Common infectious complications are:

Western inflammation spread to the skin and subcutaneous organs.

Primary peritonitis.

Urinary tract infections.

Pneumonia, a blood infection.

For many years, we still have complications of urinary tract infections, while other complications are not seen or very rare. This is related to the current regimen of better patient care, especially a diet enriched with high-protein foods.

Seizures, spasticity due to hypocalcemia

Usually manifests itself in 2 forms:

Spasticity, cramps are seen in older children.

Shrinking, cyanosis, hissing sound: rare and common in young children.

Currently, the use of calcium salts in combination with Vitamin D has significantly reduced the rate of children with seizures, spasticity due to hypocalcemia.

Severe abdominal pain

Abdominal pain is the result of decreased circulating volume, atelectasis of deep veins in the mesenteric lining. This complication will not occur, when the patient eats enough, especially enough protein (it should be differentiated from abdominal pain due to primary peritonitis).

Ch am big and malnutrition

Children grow slowly due to prolonged or recurring illness; when the oedema is gone, the child is emaciated; thin, thin, blond hair.

Test

Urine

Quantitative proteinuria in 24 hours

In fatty kidney disease, proteinuria is highly increased:> 50 mg / kg / 24 hours (about 80% of patients have proteinuria> 100mg / kg / 24 hours).

Urinary residue:

Glomerular gap (-).

Head in (+).

Optical extraction cylinder (+).

Blood

Blood protein electrophoresis:

Total protein: much reduced to <56g / l (normally 70 - 80g / l).

+ Albumin: reduced much to <25g / l (normally 38-45g / l).

+ A / G ratio: <1.

+ α1 Globulin increased slightly (normally 4% = 0.3g / l).

+ α2 Globulin increased (normally 8% = 0.6g / l)

+ β Globulin increased (normally 2% = 0,9g / l)

+ γ Globulin decreased (normally 18% = 1.4gl)

Electrolyte:

+ Reduces blood calcium.

+ Reduce blood potassium.

+ Increased blood chlorine.

Take care of

Human determination

Evaluate the whole situation.

Ask for history and ooedema.

Examination, determination of the nature and extent of ooedema.

Results of treatment courses (if any) and course of the disease.

Test results for blood protid and proteinuria.

Nursing diagnosis

For fatty kidney patients, some commonly cited nursing diagnoses are:

Ooedema due to decreased colloidal force due to urinary protein loss Diagnosis is based on the symptoms:

Swollen or very loud.

Fluid in the serosa.

Reduced blood protein ≤ 56g / l.

Proteinuria ≥ 50mg / kg / day.

Less discharge due to water inside the cell and going to the cell space because of reduced glue pressure Diagnosis is based on the symptoms:

Little urine, dark yellow, viscous, foamy, long soluble.

Reduced blood protein ≤ 56g / l.

Proteinuria ≥ 50mg / kg / day.

Risk of infection due to decreased resistance Diagnosis is based on the following symptoms:

Swollen very loud.

Blood protein is much reduced.

Are taking high doses of corticosteroids.

Poor diet, lack of protein.

Poor hygiene.

Shortness of breath due to peritoneal effusion and pleural effusion Diagnosis is based on the symptoms:

Children find it difficult to breathe.

Fast, shallow breathing.

Big belly, raft, knocking chisel in the lowland. If there is pleural effusion, then on lung examination, chest evacuation with decreased breathing rate and 3 decreased syndromes.

Fever (swelling, pain in the thighs, etc.) due to infection Diagnosis is based on the symptoms:

Body temperature> 37.5 degrees Celsius.

There is an infection in the skin, muscle or elsewhere (the skin at the inflamed site appears swollen, hot, red, painful).

Urinary incontinence due to urinary tract infection Diagnosis is based on the following symptoms:

Babies urinate many times a day (15 -20 times/day or more).

During urination, the child complains of pain in the bladder or urethra.

Urine is often cloudy like rice water.

Examination of urine with many white blood cells, mainly white blood cells of large size and stick together (leukocyte casts).

Spasticity, convulsions due to hypocalcemia Diagnosis is based on the following symptoms:

Children convulsed, hands and feet stretched, pain like cramps.

It may be difficult to breathe, inhale when breathing is heard.

The tendon-bone reflex is increased.

The child is awake.

Symptoms of ooedema are greatly reduced.

Children have feelings of boredom, fear of prolonged and recurring illness. Diagnosis is based on the patient's condition:

Often complained of prolonged ooedema.

Regularly ask if the disease can be cured?

Anxious, moody, reluctant to contact, does not want to talk to physicians.

Refuse to take medicine.

Refuse to eat and drink.

Demanding to go home, do not want to lie down for treatment.

Care planning

Less swelling, urinary retention due to reduced colloidal pressure due to urinary loss of protein :

Goal: reduce ooedema, normal urination.

Nursing interventions:

Instructions for taking medicine:

Prednisolone: The dose of the whole day to take once after breakfast (at full time) with the following dosage and usage:

Initially, an attack dose of 2 mg/kg/day for 4 consecutive weeks. This is an immunosuppressive dose, meaning that it inhibits antibody production.

Then use a maintenance dose of mg/kg/day, drink 5 days a week, rest for 2 days, drink for 8 weeks.

Finally, a fortified dose of 0.3 -0.15 mg/kg/day is used, for 4 consecutive days a week, 3 days off, and for 3 months.

During high dose Prednisone to children to drink potassium salt, because Prednisolone effect of increasing potassium excretion. If potassium chloride is given to drink, it must be dissolved with enough water to have a concentration of <10%, in order to avoid an irritating effect on the stomach.

Vitamin D: for 1000vnd / day, drink away from meals (between 2 meals).

The purpose of using Vitamin D is to increase absorption of Ca ++ from the intestine into the bloodstream to prevent Tetani complications and to avoid osteoporosis complications caused by Prednisolone. Children can be sunbathed every morning if vitamin D is not available.

Give your child calcium salt 1 -2g / day while taking Vitamin D.

Diet:

Advise family members to eat a variety of protein-rich foods such as fish, meat, eggs, and milk. This is the decisive factor to increase the amount of protein in the blood, reduce ooedema and make the child urinate more.

Advise children to eat foods rich in potassium such as duck eggs, eggs, carp, catfish, crab, beef, liver, body, lean meat, cow's milk, oranges, lemons, jackfruit, banana, plum, carrot, potato, taro, copra, corn, cabbage, squash, spinach, water spinach, Sam ...

Recommended for children to eat relatively light during the time using Prednisolone because Na is retained by using Prednisolone concomitantly by the effects of Aldosterone.

Give the child normal water.

Maintain food hygiene, personal hygiene, bedding and the environment because the child's resistance is very reduced (due to decreased blood protein, especially reduced myoglobulin and high doses of Prednisolone).

Risk of infection due to decreased resistance:

Goal: Prevent infection.

Nursing interventions:

Maintaining personal hygiene, eating and drinking hygiene, bed hygiene and the environment.

Give your child a variety of protein-rich foods such as fish, meat, eggs, milk ...

Keep the baby warm, avoiding cold infection.

Fever caused by infection:

Goal: temperature return to normal.

Nursing interventions:

Give children antipyretic drugs: Paracetamol 10 -15mg / kg / time.

Loosen sweaters, cotton shirts ...

If the feet are cold, it is recommended that the family wear socks for the child.

Take antibiotics as directed by your doctor.

15 - 30 - 60 minutes after giving fever-reducing medication, the child's temperature must be monitored. If after 1 hour the body temperature has not decreased <38o5, then give fever-reducing medicine again.

Shortness of breath due to peritoneal or pleural effusion:

Goal: Child breathes normally.

Nursing interventions:

Instructions for children to sit in the Foller position (half lying, half sitting).

Encourage your child to try to eat lots of fish and meat.

Performs a plasma infusion command (currently rarely used).

Prepare a pleural probe (if indicated).

Children with spasticity of legs and arms due to hypocalcemia:

Goal: The child stops spasticity of limbs.

Nursing interventions:

Intravenous injection of calcium chloride (or calcium gluconate) 0.5g. Note: must be injected acupuncture and must not be injected off the vein.

Guiding children to take calcium salts with Vitamin D.

Children are afraid to urinate because of pain and burning when they urinate:

Goal: The child is not afraid to urinate (no pain, no burning when urinating).

Nursing interventions:

Encourage children to take antibiotics according to the command (Cotrimoxazole 48 mg/kg divided 2-3 times/day when full).

Encourage your child to drink plenty of fluids, if there are no contraindications.

Encourage children to urinate often, avoiding stagnant urine.

Clean the genitals after each urination.

Children and family try to feel bored, fearful because of long-term and frequent illnesses:

Objectives: To make children and family feel reassuring, trusting, and persistent in treatment.

Nursing care:

Encourage your child and family to believe in the results of treatment:

Talk about the cure results of some children with fatty kidneys.

Make clear about the harmful effects of anxiety, not assured in treatment.

Explain to family members clearly about the meaning of motivating and encouraging children in treatment.

Encourage the child and family to comply with the command:

Talk about the value of a protein-boosting diet.

Talk about the value of taking Prednisolon in the right dose, enough time, and the harm of taking it incorrectly.

Clarify the benefits of personal hygiene, food hygiene and environmental hygiene.

Fatty kidney disease is an autoimmune, chronic, recurring disease that goes back many times, lasting for many years, but still can be completely cured in 80% of patients, if the child is properly treated and cared for.