Diagnosis and treatment of elderly patients with chronic kidney disease - CKD integrated treatment

Early detection of kidney disease progression , given intervention ; delay the occurrence of renal dysfunction and progression , prevention of complications of uremia occurred ; perfect preparation before renal replacement therapy , timely start and run properly ; comprehensive quality and ability to return to life in society improve ; this continuous process that chronic renal insufficiency integration therapy.
Treatment goals are: to remove toxins , relieve symptoms , slow disease progression .
First, the non-dialysis treatment :
1, the treatment of the primary disease and correct reversible factors of vital early treatment of primary glomerular disease , such as primary nephrotic syndrome , minimal change nephrotic through regular hormonal treatment can complete remission ; membranous nephropathy early hormones and cytotoxic drugs to treat about 60 % of patients can be alleviated ; secondary nephrotic syndrome , diabetic nephropathy is the early detection of diabetes and timely control of blood pressure , blood sugar and other treatment can slow the progression of kidney disease ; for atherosclerosis due to renal artery stenosis , stricture intervention by other methods, can improve the symptoms of stable renal function. For obstructive nephropathy , promptly relieve urinary tract obstruction is key to preventing deterioration of renal function .
2 , high-calorie, low-protein diet is a diet therapy is an important measure for the treatment of CRF in the early going with impaired renal function implementation . Develop a reasonable diet regimen : adequate intake of protein (0.6g-0.8/kg/d) and a sufficient amount of calories (30 ~ 35 kcal / kg / d); purposes of low-protein diet, especially when low -protein diet therapy, should be added a- keto acid compound preparation or formulation of essential amino acids and proper vitamins, minerals and trace elements. If hypertension , edema , etc. , to use the low-salt diet ( 2g daily salt or soy sauce 10ml), elderly patients renal tubular sodium security function decline , beneath salt tendencies, none of the above situations who do not have too much restriction. Elderly patients with gastrointestinal dysfunction , nutritional intake less , if too much emphasis on diet composition , may be due to food varieties too monotonous , tedious cooking , and eating too few patients with malnutrition . Therefore , to deal with the nutritional status of elderly patients be closely monitored , attention guidance on diet recipes , change bad eating habits and avoid malnutrition.
3 , the process of treatment of CKD complications can occur in cardiovascular , blood , bones, endocrine , respiratory and other complications , is both a result of CKD progression of these complications , but also lead to disability of patients , the direct cause of death.
( 1 ) Hypertension Hypertension is both a cause of CKD , is one of its major complications . Strict control of blood pressure is slow kidney disease progression and reduce the basis of cardiovascular events. No albuminuria control blood pressure in patients with CKD continues ≤ 140/90 mmHg; CKD patients with albuminuria continued ≤ 130/80 mmHg, which is important , especially systolic blood pressure treatment compliance . CKD patients with early rapid drop in blood pressure (SBP 110mmHg or less ) will lead to increased cardiovascular and cerebrovascular events , accelerated loss of kidney function , blood pressure should therefore be stable for long-term benefits . Renovascular hypertension is difficult to control , often prone to malignant hypertension , need multiple drugs ( 3-4 ) conventional doses ( 1-2 tablets ) used in combination , as ACEI or ARB better than other antihypertensive drugs for organ protection therefore, as a first choice, can be combined with diuretics , CCB. Combination of complementary mechanisms , the antihypertensive effect of adding the offset adverse reactions . Faster than monotherapy blood pressure standards.
( 2 ) the treatment of anemia anemia caught three basic aspects : Supplementary erythropoiesis stimulating agent (ESA); positive iron , transferrin saturation should be> 20% , serum ferritin should be > 100ng/ml, to ensure that blood raw materials ; found and correct a variety of other factors that promote or CKD anemia effects: as all kinds of inflammation, infection, bleeding , metabolic acidosis , malnutrition , lack of .... carnitine . The goal of treatment is : Hb at ​​110 ~ 120g / L, hematocrit 33 % to 36% ; Hb levels and to maintain stability.
ESA is currently applied in the treatment of CKD products reach far beyond the level of physiological EPO EPO levels , and thus lead to many consequences: high blood pressure, vascular disease , thrombosis . rHuEPO better than a few times to give a large dose ; subcutaneous better than intravenous injection ; intravenous iron easily absorbed , can reduce the EPO dose. Due to the use of EPO way inconvenient , often associated with cardiovascular complications , require larger doses of iron supplements , expensive problems , recently produced a number of new drugs : Improving the role of EPO structure makes it a long time to reduce the frequency of use , such as Dabepoetin ( up according to epoetin α) once every two weeks , Micera_ once a month ; Hematide one can be administered orally , sustainable stimulate erythropoietin receptor dimer peptide synthesis to achieve the correction of anemia , relatively inexpensive , especially its structure and EPO completely not relevant , in aplastic anemia, pure red can be used ; there hypoxia inducible factor (HIF) stabilizers or HIF prolyl hydroxylase inhibitor (FG-2216, FG-4592) can also be taken orally.
( 3 ) metabolic acidosis is the most common complication of CKD. Light oral sodium bicarbonate tablets 1-4g, 3-4 times daily to correct acidosis , weight can be 5 % sodium bicarbonate 150-200ml, for intravenous infusion. If you have low blood calcium , and who , in the alkaline liquid supplement , as appropriate, should supplement calcium gluconate agent, in order to avoid a decrease in serum free calcium tetany occurs . In addition, pay attention to the process of correcting changes in serum potassium . Stubbornly difficult to correct acidosis , dialysis is the only correct acidosis carbonate safest and most effective way.
( 4 ) prevent hyperkalemia or hypokalemia potassium balance in uremic patients prone to disorder, oliguria , anuria and patients vulnerable to hyperkalemia acidosis occurs , followed may lead to arrhythmia, ventricular fibrillation, cardiac arrest and endangering the patient's life , should reduce the intake of potassium , disable potassium sparing diuretics and correction of acidosis . Vomiting, anorexia, patients prone to long-term diuretic hypokalemia, Seoul , following the occurrence of life-threatening heart rhythm disorders . For patients with hypokalemia , potassium supplements or potassium food and other drugs . ?
( 5 ) renal osteodystrophy bone disease can be divided into ① high transporters , namely A hyperparathyroidism and osteodystrophy osteitis ; ② low transport osteodystrophy , osteomalacia , and is without power osteodystrophy ; ③ mixed osteodystrophy , bone disease of hyperparathyroidism and bone mineralization disorders coexist. Occurred relatively early stage CKD (GFR <30 ~ 40ml/min); appear hyperphosphatemia , hypocalcemia, 1,25 (OH) D3 and secondary hyperparathyroidism ; but symptoms appeared later , there are bones , joint pain , fractures , itchy skin , soft tissue calcification. For high transport osteodystrophy , elevated PTH patients should limit the intake of dietary phosphate , if low or normal calcium levels should be treated simultaneously phosphate binders ( calcium carbonate, calcium acetate ) and active vitamin D . If you subtract the low transport osteodystrophy or disable active vitamin D, if necessary, plus calcitonin ( Miacalcic ) symptomatic avoid tissue calcification .
4 . Promote excretion of metabolites ?
① new clean tablets 3 to 5 , or Niaoduqing 5g, or Shenshuaining tablets, 3 to 4 times / day orally. ② oxidized starch 10g or package aldehyde oxidized starch 5-10g, 2-3 times daily blunt. ③ dialysis powder, or ion exchange resins, or medicine , oral cathartic , but also colon dialysis , once a day.
? Addition , should intervene risk factors , smoking cessation, control of diabetes , correct lipid metabolism disorders, and other anticoagulant treatment and prevention of atherosclerosis .
(B ) dialysis
In non- dialysis treatment can not be maintained , appropriate early use of blood purification therapy . Generally considered indications for dialysis uremic symptoms ; plasma creatinine value reached 707umol / L (8mg/DL) above ; urea nitrogen reached 30mmol / L (80mg/dL) above ; and / or creatinine clearance less than 10ml/min , the can be used dialysis. For uncontrolled hypertension, or high degree of edema , anuria oliguria, or complicated by heart failure , pulmonary edema, cerebral edema ; merger pericarditis , neurological symptoms and severe metabolic acidosis , electrolyte imbalance may emergency dialysis therapy . As for the use of hemodialysis, peritoneal dialysis or hemodialysis should be based on a comprehensive analysis of colon disease , economic conditions, equipment and technical personnel may be. Conditional feasible kidney transplantation is an effective measure for the treatment of advanced CKD . Because renal replacement therapy has its own unique effect on the treatment of patients with end-stage renal failure is no longer simply to give a kidney transplant or dialysis treatment , but according to changes in the patient's condition can change at different stages of renal replacement therapy to improve survival and quality of life of patients .
To be noted that CKD patients treated properly, can often remain relatively stable for several years in the pathogenesis of renal function or even decades , the key is to do the daily life of diet regulation, attention to the protection of residual renal function .