I. Western medical diagnosis name: acute renal failure
Definition: Acute renal failure is a rapidly and continuously aggravated azotemia caused by various etiologies, with or without oliguria (daily urine volume less than 500ml), and can be divided into three types of prenephrosis, nephrosis and postnephrosis (obstruction) according to etiology.
It is seen in the middle and late stages of certain warm fever diseases and the end stage of edema, fornication, gonorrhea, dropsy, etc. It is a critical symptom caused by abnormal elevation and flow and closure of yin and yang.
3. Etiology and pathology
1.Western medicine etiology and pathology
Western medicine believes that there are many different causes of acute renal failure, and acute tubular necrosis is the most common and characteristic cause. Acute tubular necrosis has two main categories: ischemia and nephrotoxins, the latter including exogenous toxins (biotoxins, chemical toxins, antibacterial drugs, contrast agents, etc.) and endogenous toxins (hemoglobin, myoglobin, etc.). The former is dominated by a dramatic decrease in cardiac beat volume due to various causes and a severe shortage of extracellular fluid, especially intravascular fluid, making the kidneys insufficiently perfused. Severe cardiopulmonary, hepatic, and renal diseases, infections, and irrational application of drugs affecting renal hemodynamics, such as nonsteroidal anti-inflammatory drugs, are often causative factors. The above causes lead to abnormal renal hemodynamics, metabolic disorders of renal tubular epithelial cells, detachment of renal tubular epithelium, and formation of tubular pattern in the lumen.
2.Chinese medicine etiology and pathogenesis
Deficiency of yin and yang in the kidney, loss of qi and blood, and water toxicity, dampness, blood stasis, etc., or both external evil, invasion of the three jiao, lung, spleen. It is formed by the malfunction of the three organs of the kidney. Although the kidney is the main site of the disease, multiple organs are involved, making the condition variable and complex.
Clinical typology
(1) Cloudy evil clouding the heart, manifested as obstruction of the bowels, frequent vomiting, restlessness, delirium, or twitching of the limbs, slippery tongue coating, and slippery pulse.
(2) The evidence of turbid evil offending the stomach, manifesting as frequent nausea and vomiting, shortage of urine, bitterness in the mouth and distress in the heart, abdominal distension and bowel obstruction, dizziness and palpitation, yellow and greasy tongue coating, red tongue texture, and string pulse.
(3) The evidence of downward movement of turbid evil, manifesting as little or no urine, generalized swelling, dull and dark face, fatigue and drowsiness, foul urine in the mouth, cold form and cold limbs, itchy skin, fat and tender tongue, thin white and slippery moss, and sunken and weak pulse.
IV. Clinical manifestations
The disease starts with inability to pass urine, followed by frequent vomiting, nausea and Qi rebellion. Nausea and vomiting are intermittent. There is a foul smell in the mouth and ammonia in the breath. Some patients may have abdominal pain and loss of appetite. A few patients also have vomiting blood and blood in stool. In addition, there are pallor, depression, dizziness and headache, palpitation and edema, skin itching, etc.
V. Laboratory and other tests
Urine examination is very important for this disease, such as the amount of urine, the change of specific gravity, and the change of urine sediment. In prerenal, the specific gravity of urine is more than 1.020, while in postrenal or acute tubular necrosis, isotonic urine is present. Urine protein is most frequent in glomerulopathies and often less frequent in other acute renal failures. The presence of erythrocyte tubular pattern in the urine is favorable to consider caused by glomerulonephritis or vasculitis. Brown urine, when centrifuged and visible containing most tubular epithelial cells, is important for the diagnosis of acute tubular necrosis. A high number of eosinophils in the urine is suggestive of interstitial nephritis. A large number of uric acid crystals, combined with a high blood uric acid level, will mostly confirm the diagnosis of acute hyperuricemia caused by nephropathy. The presence of a pigmented tubular pattern suggests hemoglobin or myoglobinuria.
Blood biochemical examination, such as blood creatinine, urea nitrogen, blood potassium, sodium, calcium, phosphorus, plasma dioxide binding capacity, etc., is beneficial to the diagnosis and differential diagnosis of the disease.
In addition, renal ultrasound, x-ray and imaging examination can be performed, and renal puncture can be considered in difficult cases.
Diagnosis and differential diagnosis
1.Diagnosis
It is not difficult to make a diagnosis based on medical history, clinical manifestations and relevant laboratory tests.
2. Western medicine differential diagnosis
In the diagnosis, attention should be paid to distinguish which kind of disease belongs to. Pre-renal: caused by insufficient blood volume, reduced cardiac output, sepsis or excessive use of vasodilatory antihypertensive drugs or diuretics, as well as various causes of shock to reduce renal perfusion blood flow, physical examination reveals dry skin and mucous membranes, postural hypotension, and inconspicuous jugular venous filling, pre-renal acute renal failure should be considered first; renal: refers to renal substance, such as glomerulonephritis, acute interstitial nephritis, acute renal tubular necrosis, etc. If there is a history of muscle crush and obvious convulsions, acute tubular necrosis caused by rhabdomyolysis should be noted. The presence of rash, fever, and arthralgia often suggests acute interstitial nephritis caused by drug allergy. Acute renal failure due to systemic diseases, including systemic lupus erythematosus, Wegener’s granulomatosis, or systemic vasculitis, should be highly suspected if there are obvious systemic symptoms, such as skin, joint, lung, central nervous, and gastrointestinal symptoms. Sudden onset of swelling, hematuria, hypertension, bleeding and exudation from the fundus, and severe arterial spasm should suggest renal substantial acute renal failure caused by acute nephritis or malignant hypertension; post-renal: refers to complete urinary tract obstruction caused by prostate stones or tumors, etc.
3. Chinese medicine class evidence identification
Retention of urine: It refers to a disorder in which the amount of urine is small, dripping out, or even small so that the occlusion does not work as the main symptom. Generally, there is no symptom that can be seen together with frequent nausea and vomiting. This can be distinguished from both of them.
VII. Treatment
1.Western medicine treatment
(1) Active control of the primary disease, early correction of hypotension, hypovolemia and electrolyte balance disorders.
(2) Treatment of oliguric phase: strictly control water intake, limit protein intake and supply enough calories, control sodium and potassium salt intake, especially potassium salt, avoid drug abuse and regulate the dose of drugs excreted from the kidneys. If possible, dialysis therapy should be used as early as possible, and peritoneal dialysis and hemodialysis treatment should be chosen according to the situation, and concurrent infections should also be treated actively.
(3) Treatment of polyuria: In the first 1 or 2 days, the treatment should be based on the principles of oliguria. After 2 or 3 days of heavy urination, we should prevent dehydration, hypokalemia and hyponatremia, pay attention to timely supplementation, and supply enough calories and vitamins.
2.Chinese medicine treatment
(1) Cloudy evil clouding the heart, the treatment is based on diarrhea and opening the orifice, laxative and diuretic. The main formula is to use warm bile soup plus or minus. The medicine is used in the method of half a summer, bile South Star, Citrus aurantium, Poria, calamus, bamboo, diarrhea, psyllium, rhubarb, etc.. At the same time, it can be instilled or nasal feeding of Zhi Bao Dan,
In addition, enema, external application and acupuncture therapy should be used in combination.
(2) turbid evil offending the stomach, the treatment is to harmonize the stomach and lower the rebellion, stop vomiting and water. The main formula is Huanglian Wenzhi Tang with addition and subtraction, using Huanglian, Zhu Ru, Hovenia, Chen Pi, Fa Xianxia, Ze Di, and Liu Yi San. At the same time, enema, external application and acupuncture should be used in combination.
(3) The treatment is to benefit the kidney, support the spleen, lower the turbidity and detoxify the water. The main formula is Wen Spleen Tang with addition and subtraction, using rhubarb, Shu Pill, dry ginger, Radix Codonopsis, Fructus Semen, Cornus Officinalis, Zegeolus, Mouton, Danshen, Angelica, Lonicera, etc. In combination with acupuncture and moxibustion, etc.
The emergency department agreement prescribes anti-inflammatory compound, which has the effect of clearing heat and detoxifying the toxins and clearing turbidity from the internal organs. Take 25ml orally twice a day.
VIII. Prognosis
This disease is a critical illness and requires active diagnosis and treatment, otherwise the prognosis is poor.
9. Chinese medical care
Protect the skin, itchy skin should be scrubbed with warm water, no soap or alcohol, do not scratch, to prevent the evil poison from entering the inside.
Regulate the living and prevent colds. If colds occur, treat them promptly, otherwise the condition may deteriorate.
X. Assessment of therapeutic effect
If the patient vomits frequently, urine volume continues to decrease, and blood creatinine and urea nitrogen continue to rise, it means the condition is deteriorating; on the contrary, it means the condition tends to improve.