With the increasing incidence of hypertension, atherosclerosis, diabetes mellitus and the aging of the population, the incidence of end-stage renal disease has also increased significantly. According to incomplete statistics, there are about 150-200 cases of ESRD per million people in China. The so-called “integrated ESRD treatment” refers to timely and early diagnosis of ESRD, timely initiation of renal replacement therapy, protection of residual renal function, delaying the progression of the disease, prevention and treatment of its complications, as well as education and guidance about the disease, so that ESRD patients can achieve the best quality of life and restore their working capacity as much as possible. The following are some examples
1. Timely and early diagnosis
Popularize the knowledge of kidney disease, and refer patients to kidney specialists for treatment once the progression of kidney lesions is detected. For patients with chronic kidney disease, give early treatment, education and guidance to slow down the development of chronic renal failure; when the development reaches the stage of ESRD, give renal replacement therapy in a timely manner. At present, it is common in China to start renal replacement therapy too late, resulting in a higher incidence of various complications (such as infection, heart failure, malnutrition, etc.), higher hospitalization rate, higher total medical costs, and unprotected survival and quality of life of patients with ESRD.
2.Improve the preparation before renal replacement therapy
Educate patients and their families about the necessity of renal replacement therapy and the advantages and disadvantages of various therapies, so that they can prepare and accept the replacement therapy psychologically and physiologically. Establish dialysis access. For those who are ready for peritoneal dialysis, it is better to start dialysis 2 weeks after the implantation; for those who are ready for hemodialysis, it is better to start dialysis 2 months after the establishment of arteriovenous endovascular fistula.
3.Start renal replacement therapy at the right time
Regarding the start time of renal replacement therapy, foreign scholars proposed the concept of “timely and healthier start”, that is, to start renal replacement therapy before the patient shows obvious symptoms of uremia, in order to improve the patient’s health status and reduce the complications caused by uremia.
4.The choice of renal replacement therapy
Currently, renal replacement therapy includes dialysis (hemodialysis, peritoneal dialysis and other blood purification therapies) and kidney transplantation.
(1) Peritoneal dialysis
Using the patient’s peritoneum as a semi-permeable membrane, the solute concentration gradient and osmotic gradient between plasma and peritoneal dialysis fluid are used to remove toxins and correct disorders of water and electrolyte metabolism and acid-base balance. Compared with hemodialysis, early peritoneal dialysis in ESRD patients can effectively remove medium-molecule substances, protect residual renal function, and maintain stable cardiovascular function. Therefore, peritoneal dialysis should be the first choice of dialysis treatment for ESRD patients. The survival rate of patients treated with peritoneal dialysis is higher than that of hemodialysis patients in the first 2 years of starting dialysis treatment. However, it is worth noting that survival rates for peritoneal dialysis treatment are currently still lower than those for hemodialysis, and peritonitis is the predominant factor among the reasons for withdrawal from peritoneal dialysis treatment, followed by inadequate dialysis (including inadequate solute clearance and insufficient water clearance). In recent years, the hot topic of research on peritoneal dialysis is how to improve the biocompatibility of dialysis fluid and increase the efficiency of dialysis.
(2) Hemodialysis
With the combination of modern science and technology and medical treatment, hemodialysis devices have been gradually improved, such as the improvement of dialysis membrane biocompatibility and the use of high-flux filters, making dialysis more and more effective. Hemodialysis treatment is performed three times a week for 4 to 5 hours, and is highly effective in eliminating most of the small molecules as well as some of the medium and large molecules accumulated in the body. Currently, there are various modes of hemodialysis such as hemodialysis, hemodialysis filtration, and continuous hemodialysis filtration for patients with different conditions. However, hemodialysis also has some problems, such as: ① even the most effective hemodialysis treatment can only be equivalent to 10-20% of the normal double kidney clearance efficiency of small-molecule solutes, while the clearance of large-molecule solutes is even more inadequate; ② there is instability of blood pressure in dialysis, and the protection of residual kidney function is poor; ③ the infection rate of hepatitis B virus and hepatitis C virus infection in dialysis patients is high; ④ the establishment of vascular (3) the establishment of vascular pathways has a greater impact on hemodynamics and cardiac function, etc.
(3) Kidney transplantation
For ESRD patients, kidney transplantation is the best option to restore a healthy and viable life. Successful kidney transplant recipients have significantly better life satisfaction, physical and emotional comfort, and ability to return to work than dialysis patients, and kidney transplantation can correct or improve comorbidities of uremia that cannot be completely reversed by dialysis treatment, such as anemia, peripheral neuropathy, autonomic neuropathy, and sexual dysfunction. At present, renal transplantation surgical techniques have largely matured, and transplantation immunology has also made great progress. The clinical application of various new immunosuppressive drugs has enabled kidney transplant patients to achieve 1-year and 5-year survival rates of more than 90% and 70%, respectively. For example, the new triple therapy regimen of cyclosporine or tacrolimus (FK506) plus mycophenolate mofetil (MMF) plus prednisone has significantly reduced the incidence of acute rejection after renal transplantation; biological immunosuppressive drugs such as anti-thymocyte globulin and anti-lymphocyte globulin have been used to treat acute rejection with a reversal rate of 70% to 100%. ～However, there are some shortcomings in kidney transplantation. However, there are some shortcomings in kidney transplantation.
(i) the apparent lack of kidney sources and the prolonged waiting time for kidney transplantation in ESRD patients.
(ii) The current doses of major immunosuppressive drugs are close to toxicity, so they must be used rationally and their blood concentrations must be measured regularly to adjust the dosage.
(iii) The immunosuppressive state of the organism causes an increased incidence of postoperative infections and tumors.
(iv) The presence of recurrence of primary disease and chronic transplant nephropathy after renal transplantation affects the long-term survival rate of the transplanted kidney.
In conclusion, physicians should choose the renal replacement therapy that best fits the patient’s condition (including disease condition, physical condition, vascular condition, work and living habits, economic conditions, etc.), combined with local medical and technical conditions. If the patient’s clinical and practical conditions permit, peritoneal dialysis should be the first choice, and as the residual renal function gradually decreases, the dialysis dose should be gradually increased to replace the deficiency of the residual renal function; later, as the dialysis time is extended, the dialysis mode can be changed from peritoneal dialysis to hemodialysis or renal transplantation according to the changes in the patient’s condition; it can also be changed from hemodialysis to peritoneal dialysis or renal transplantation; if the transplantation If the transplantation fails, it can be changed back to the integrated treatment of dialysis.
5. Strengthen the management of ESRD patients and management of complications
Improving the survival rate of ESRD patients is a comprehensive and long-term systematic project centered on renal replacement therapy. However, there are still a considerable number of medical personnel who lack the concept of ESRD treatment integration, see renal replacement therapy simply as a technical operation, but cannot look at it from the height of clinical treatment, and lack comprehensive medical management and guidance for patients. When patients with various chronic kidney diseases develop to ESRD stage, metabolite retention, imbalance of water, electrolyte and acid-base balance as well as multi-system functional impairment of digestive system, hematological system and cardiovascular system will occur, such as renal anemia, renal osteodystrophy, hypertension, heart failure, etc. Reasonable correction of the complications of ESRD can significantly increase the survival rate and improve the quality of life of patients.
6. Strengthen the mental health guidance of ESRD patients
Patients on maintenance dialysis treatment are prone to various psychological problems, such as depression, anxiety, frustration, despair and rebellious behavior, due to disease, family and social factors, which often cause patients’ quality of life to decline, and individual patients may discontinue dialysis or even commit suicide. This requires medical and nursing staff of renal and psychological specialties to provide psychological guidance to patients. It is imperative that medical workers should strengthen the awareness of integrated ESRD treatment, recognize the treatment goals, seek the support and cooperation of patients and their families, and work together to improve the survival rate, quality of life and social return rate of ESRD patients.