Hospital traditional treatment of renal failure

Hospital traditional treatment of renal failure
Treatment of chronic renal failure include medical therapy, dialysis and renal transplantation, dialysis and kidney transplantation in patients with end stage renal failure is undoubtedly the best treatment choice, but because these treatments are expensive and not always available for a limited renal origin acceptable for most patients, in addition, some patients with kidney disease progress to end-stage renal failure before, through reasonable medical therapy can delay the progress of the disease progression, a few are still capable of completely reversed, therefore, should pay attention to chronic renal failure of conservative treatment.
1 primary disease treatment and incentives: For CRF patients the initial diagnosis, we must attach importance to the diagnosis of active primary disease, chronic nephritis, lupus nephritis, nephritis, IgA nephropathy, diabetic nephropathy, etc., are required to maintain long-term treatment, it also should be actively looking for a variety of predisposing factors CRF reasonably correct these incentives may make the disease and reduce or stabilize a greater degree of improvement in renal function.
2 Diet: Chronic renal failure diet over the years is considered to be its basic treatment measures for national scholars respected, following to diet therapy is generally limited to the application of low-protein diet, but long-term low-protein diet may affect the nutritional status of patients Research shows that malnutrition in chronic renal failure rate as high as 20% to 50%, severe malnutrition is now considered to be an independent risk factor for CRF, was directly with the prevalence and mortality are related, and therefore, the current diet are more likely to patients develop a more rational nutrition regimen.
(1) determine the index patients with chronic renal failure malnutrition: chronic renal failure patients on nutritional status monitoring and evaluation methods include biochemical, ergonomic measurements, body composition analysis and dietary assessment (Table 2), each of which method has some limitations, must be considered.
(2) formulate nutritional therapy in patients with CRF: CRF patients with nutritional therapy program to be based on the level of kidney function in patients with different causes (such as diabetic nephropathy, hypertension, chronic nephritis, etc.), nutritional status, food intake and digestion, eating habits etc. to develop, as far as possible individual, in principle, should help patients maintain a good nutritional status, or to malnutrition improved; for pre-dialysis patients, should be considered to help control kidney underlying diseases, protect renal function , when developing nutrition therapy, patients should first ensure protein - amino acids full intake, and taking into account the vitamins, minerals and other nutrients intake, has emphasized the role of high-protein diet in renal disease progression in the pathogenesis, therefore, for pre-dialysis patients with CRF is still low-protein diet based, and according to the degree of renal damage varies, generally Ccr 20 ~ 40ml / min (Scr 176.8 ~ 353.6μmol / L) when the protein intake (PI) for 0.7 ~ 0.8g / (kg · d); Ccr 10 ~ 20ml / min (Scr 353.6 ~ 707.2μmol / L), PI of 0.6 ~ 0.7g / (kg · d); Ccr <10ml / min (Scr≥707.2 μmol / L), PI was 0.6g / (kg · d).
The diet is now widely used in protein intake 0.6g / kg body weight, of which 64% of the protein is plant protein, animal protein 46%, per day may provide 35kcal / kg calories, 0.6g / kg protein, 600mg of phosphorus, 110g 320g of lipids and carbohydrates, in addition, would like to add a sufficient amount of trace elements and vitamins.
For the quality of the protein should also be considered, containing essential amino acids are generally administered (EAA) high content of food, the main source of calories as the staple food, the selection of the lowest possible protein foods (Table 3) for hemodialysis patients is no need to strictly limit protein intake, the general should keep 1.0 ~ 1.4g / (kg · d), essential amino acids or α- keto acid supplements for chronic renal failure patients has its own unique effect, because in CRF patients had significantly advanced the necessary amino acid deficiency, while the ordinary dietary protein essential amino acids were lower than 50%, it is difficult to meet patient needs, and exogenous essential amino acids, the essential amino acids the body can / essential amino acid imbalance was corrected, and thus help to improve protein synthesis, also can reduce the formation of nitrogen metabolites.
α- keto acid (α-KA) is an amino acid precursor, through the transfer of an amino group or an amino role in the body can be converted to the corresponding amino acid, and its effect is similar to the EAA, and has the following advantages:
① urea nitrogen generation rate and BUN decreased more significantly, the rate of protein synthesis and degradation increased.
② can reduce phosphorus alkaline phosphatase and PTH levels.
③ In animal experiments, α-KA no cause elevated GFR or albumin excretion phenomenon.
④ delay CRF progress.
Commercially available α-KA preparations renal Tablets based, usually every 4 to 8, 3 times / d, side effects of long-term use is not obvious, a minority of patients (5%) may appear hypercalcemia, withdrawal or reduction after the drug can heal, so caution in patients with hypercalcemia or disabled.
EAA supplement by oral and intravenous infusion performed in two ways, the latter is more suitable for patients with loss of appetite, oral usual dose is 4 times / d, each 14.5g, intravenous infusion of 200 ~ 250ml / d or 0.2 ~ 0.3g / (kg · d), currently in clinical many advocates low-protein diet with EAA or α-KA and other combination, it was reported that this program not only applies to the pre-dialysis patients, but also for dialysis patients without causing severe malnutrition, calorie intake generally should be 30 ~ 35kcal / (kg · d), nitrogen (g) calories (kcal) intake ratio should be 1:300 - 1:400, in order to ensure the rational use of protein and amino acids to reduce tissue protein decomposition, to really add protein, amino acids negative effects caused by nitrogen, which carbohydrates should account for about 70% of caloric intake; fat intake should be noted that polyunsaturated fatty acids (PUFA) and saturated fatty acids (SFA) ratio ≥1, increasing the PU-FA intake, patients can improve lipid metabolism, reduce the extent of atherosclerosis.
Note added water-soluble vitamins, especially vitamin B6 and folic acid, according to the condition supplement minerals and trace elements such as iron and zinc.
In addition, nutritional therapy in patients with CRF also includes some supplementary drug applications, past application of testosterone propionate, Nandrolone and other drugs to promote protein synthesis, but due to limited efficacy, does not currently recommend, in recent years, reported the human recombinant growth factor (r-hGH) and insulin-like growth factor (r-hIGF-1) treatment in patients with CRF malnutrition, efficacy is still good, others such as correction of acidosis and electrolyte imbalance, giving gastric motility drugs such as domperidone (domperidone), orally active vitamin D and correcting renal anemia preparations r-hEPO, etc., to correct malnutrition CRF have a certain effect.
3 replacement therapy include: hemodialysis, peritoneal dialysis, kidney transplantation, the highest quality of life in renal transplantation, serum creatinine greater than 707μmol / L or GFR <10ml / min (diabetic patients <15ml / min), and the patient began to appear when uremia clinical manifestations can not be relieved by the treatment, they should do the dialysis treatment, the patient had to be mentally prepared for hemodialysis, peritoneal dialysis or a kidney transplant to make a choice, usually a period of dialysis should be considered only kidney transplant, dialysis therapy of renal excretory function alternative, but not a substitute for endocrine and metabolic functions, similar to hemodialysis (referred to hemodialysis) and peritoneal dialysis (PD for short) effect, each with its advantages and disadvantages, in clinical applications can complement each other.
(1) hemodialysis: should advance (before hemodialysis weeks) do move - arteriovenous fistula (vascular access); dialysis time weekly ≥12h, usually done three times a week, every 4 ~ 6h; adhere to adequate and reasonable dialysis, which can effectively improve the quality of life of patients, many patients can survive more than 20 years.
(2) peritoneal dialysis: continuous ambulatory peritoneal dialysis (CAPD) the efficacy of uremia and hemodialysis same, CAPD especially for cerebral vascular complications in patients determined to diabetes, the elderly, children or patients do move - arteriovenous fistula difficulties, CAPD is continuous dialysis, uremic toxins continuously been cleared, a small hemodynamic changes and protect residual renal function than hemodialysis for patients with cardiovascular disease compared with hemodialysis security, use double-system, the incidence rate of complications such as peritonitis was significantly reduced.

(3) renal transplantation: a successful kidney transplant can restore normal renal function (including endocrine and metabolic functions), at present, the 1-year graft survival rate of about 85 percent, five-year survival rate of about 60%, by the body or kidney transplant relative kidney (by siblings or parents for kidney), to the ABO blood typing and a suitable basis for HLA typing, select the kidney donors, HLA matching good person, graft survival time longer need kidney transplant Long-term use of immunosuppressive agents to prevent rejection, commonly used drugs as corticosteroids, cyclosporine, azathioprine, and (or) mycophenolate mofetil (mycophenolate mofetil), etc., because the use of a large number of kidney transplantation immunosuppressive agents, and the incidence of infection in patients with increased malignancy.