Section II Acute glomerulonephritis
[Diagnosis]
I. Clinical manifestations
Acute glomerulonephritis (RPGN) is mostly seen in middle-aged and young men, with type I and II being more common in middle-aged and young adults, and type III being more common in older patients. The onset of the disease is acute, and there are mostly prodromal symptoms such as upper respiratory tract infections. In a few patients, lumbar disease and muscle pain are the main symptoms. Systemic symptoms are more severe than in patients with acute nephritis, with physical fatigue and decreased appetite. Patients who develop uremia are mostly accompanied by gastrointestinal symptoms such as nausea and vomiting, and in severe cases, acute pulmonary edema, pericarditis, and metabolic acidosis may occur. Severe oliguria or anuria is the main symptom, and renal function declines progressively in a short period of time, mostly progressing to uremia within weeks or months. Wei Lianbo, Department of Nephrology, Zhujiang Hospital, Southern Medical University
II. Examination
(I) Urine routine A large number of red blood cells and red blood cell tubular shape can be seen, urine protein is +～+++, and some patients have carnal hematuria. Leukocytes in the urine are also increased. Urine specific gravity usually does not decrease.
(ii) Blood routine There is often severe anemia, and some patients have increased blood leukocytes and platelets.
(iii) Renal function Blood creatinine and urea nitrogen are progressively increased, and endogenous creatinine clearance is progressively decreased.
(iv) Serum antibodies and complement Anti-basement antibodies may be positive in the blood in the early stages of anti-basement nephritis.
In patients with immune complex nephritis, circulating immune complexes and cryoglobulins can be detected in the blood.
(v) Anti-neutrophil cytoplasmic antibodies (ANCA) are mostly associated with small-vessel vasculitis type RPGN.
(vi) Urinary fibrin degradation products (FDP) Most patients are positive and correlate with the severity of the disease.
(vii) B-mode ultrasound The kidneys are significantly enlarged or normal with neat contours.
(viii) Renal biopsy It is the main basis for confirming the diagnosis of RPGN, with cell proliferation in the glomerular capsule and fibrin deposition, forming crescentic bodies.
III. Diagnostic criteria
With the manifestations of acute nephritis syndrome, such as hematuria, proteinuria, edema and hypertension, along with severe oliguria and progressive renal function decline, the possibility of this disease should be considered. The diagnosis is made on renal biopsy if crescent formation fills 50% of the renal capsule area and the number of glomeruli involved exceeds 50%.
[Treatment]
I. Traditional Chinese medicine treatment.
1. Congestion of lung heat, moving to the lower jiao
Main symptoms: fever, headache, cough, dry throat and sore throat, swelling of the face or body, constipation, short and red urine, red tongue, yellow fur, floating pulse (this type is mostly seen in the early stage of acute glomerulonephritis).
Treatment: Clearing the upper part of the bowels and dipping the lower part.
Radix: Liang Di Di San with addition and reduction. Rhubarb 12g, Parknip 10g, Gardenia 6g, Peppermint 10g, Scutellaria 10g, Goldenseal 30g, Forsythia 30g, Fritillaria 20g, Plantain 15g, Licorice 6g.
Addition and subtraction: If the blood in the urine is obvious with hematuria, add 15g of Radix Rehmanniae, 12g of Rootstalk charcoal and 12g of Phellodendron charcoal.
2. Dampness and heat blockage, Qi and Yin injury
Main symptoms: puffiness of the face or swelling of the whole body, fatigue, dry mouth and lips or dry throat, dizziness and tinnitus, disturbed sleep, urine with little color or hematuria, dark red tongue, thin yellow or yellowish greasy coating, moist pulse or thin and slippery (this type is most often seen in the middle stage of renal insufficiency nitrogenous hemorrhage).
Treatment: Clearing heat and dampness, tonifying the spleen and kidney
Radicals: Gan Lu Disinfectant Dan with Sheng Wei San, plus and minus. Kou Ren 12g (later), Huo Xiang 15g, Hou Pao 12g, Chuan Huang Lian 10g, Che Qian Zi (decoction) 15g, Fu Ling 15g, Zea mays 30g, Ze Di 15g, Zhen Zhen Zi 10g, Dang Shen 12g, Mai Dong 12g.
Addition and subtraction: If edema is very high, add Poria 12 g. If hematuria is heavy, add 15 g of dry lotus grass, 30 g of Radix Rehmanniae, 30 g of white foxglove root, 15 g of small thistle.
3. Deficiency of spleen and kidney yang, with internal flourishing of evil toxins
Main symptoms: depression, dull complexion, swelling, dullness, vomiting, vomiting, foul breath, urinary retention, or itching and skin petechiae, epistaxis, blood in stool, vomiting blood, blood in urine, etc., with pale tongue, thin white fur, and sunken and feeble pulse. (This type is mostly seen in the late stage of acute glomerulonephritis, i.e., the uremic phase of renal failure with swelling as the most important).
Treatment: Warming the spleen and kidney, detoxifying and draining turbidity.
Remedies: Warming the kidney and detoxifying the toxin, plus reduction. Huanglian 6g, Rhubarb 10g, mung bean 30g, Radix et Rhizoma (first decoction) 9g, Radix Codonopsis 15g, Atractylodes Macrocephala 15g, Salviae Miltiorrhiza 30g, Ginger 6g, Semen 9g, Perilla 12g.
Addition and subtraction: For itchy skin, add Radix et Rhizoma Dioscoreae 30g, Baishenpi 15g, Cicadelliae 9g, Radix et Rhizoma Bitter 15g. For heavy swelling, temporarily take Wu Pi Drink or Wu Ling San. If the edema is heavy and there is shortness of breath, chest tightness and other pericardial effusion and pleural effusion, use Zhen Wu Tang with addition and subtraction.
4. Liver and kidney yin deficiency, hyperactivity of liver and yang
The main symptoms: dizziness, dry mouth and desire to drink, lumbar weakness, numbness in the hands and feet, increased blood pressure, or even dizziness, convulsions, red tongue, thin coating, thin string pulse (this type is mostly seen in the late stage of acute glomerulonephritis, renal insufficiency uremic phase with a marked increase in blood pressure).
Treatment: Plainly tonify the liver and kidney, nourish yin and submerge yang
Radix: Tianma Gou Tang Tang Drink, 12g of Tianma, 15g of Gou Tang (later), 30g of Radix cassiae, 10g of Gardenia, 12g of Scutellaria, 12g of Dulcimer, 12g of Niubizi, 15g of Yimu Cao, 15g of Mulberry, 15g of Turtle Board (first decoction).
Addition and subtraction: 12g of calamus, 9g of yujin, 12g of bileanax, 10g of geranium, 30g of dragon bone, 30g of oyster, 12g of white peony, 10g of Xiaquan Cao in case of dizziness.
Second, Western medicine treatment.
Early diagnosis and timely “intensive treatment” is the key to improve the success rate of RPGN treatment.
1, adrenocorticotropic hormone shock therapy The first choice of methylprednisolone (10-30mg/kg.d, slow intravenous drip) shock therapy, continuous 3-5 days. After an interval of 3-5 days, one course of treatment can be repeated, for a total of 2-3 courses of treatment. This shock treatment regimen is better than oral prednisone and cyclophosphamide alone, but the efficacy is better in the early stage of treatment (creatinine <707umol/L) and less effective in the late stage. Prednisone is given orally (1-1.5mg/kg.d) and intravenously with cyclophosphamide (0.2-0.4g/time, every other day intravenously, total <150mg/kg.) Prednisone is given for 6-8 weeks, then the dose is slowly reduced (5mg every 1-2 weeks) to 0.5mg/kg.d, which can be changed to every other day in the morning and maintained for 3-6 months. Then continue to reduce the dose until the drug is discontinued.
2, combined immunosuppressive therapy that the application of prednisone 1 ~ 1.5mg / kg.d, for 8 weeks after the gradual reduction, accompanied by cytotoxic drugs such as cyclophosphamide or azathioprine, the same dose as the nephrotic syndrome. In recent years, it is also believed that intravenous cyclophosphamide (0.5 to 1.0 / m2) body surface area, once a month for 6 consecutive times) plus methylprednisolone shock therapy (0.5 to 1.0 / day for 3 days), followed by oral prednisone (1 to 1.5 mg / kg.d body weight) for 8 to 12 weeks, and then gradually reduce the dose.
3, quadruple therapy including hormones (mostly prednisone), cytotoxic drugs (such as cyclophosphamide), anticoagulation (heparin) and anti-platelet aggregation drugs (such as pansentin 400-600mg/d, for 3 months to 1 year). Among them, the dosage of prednisone and immunosuppressants is the same as before, and the general dosage of heparin is 100mg/d, and it is appropriate to maintain the prothrombin time extended to twice the normal. During use, attention should be paid to the side effects such as bleeding caused by anticoagulants.
4. Plasma exchange is mainly used for ①Good-pasture syndrome with pulmonary hemorrhage; ②Early anti-GMB antibody-mediated acute glomerulonephritis. 2-4 L should be exchanged daily or every other day, while hormones and cytotoxic drugs should be used in combination (dosage as before). Plasma exchange has good efficacy for both I and II, but it should be administered early, i.e., when creatinine <530umol/L is effective in most patients.
5. Symptomatic treatment includes antihypertensive, infection control and correction of water and electrolyte acid-base balance disorders.
6.Renal function replacement therapy For patients who enter end-stage renal disease after treatment is ineffective, they should be treated with dialysis. Patients with blood creatinine >530umol/L in the acute stage should also be treated with dialysis as soon as possible to provide immunosuppressive treatment. Those with stable disease and negative circulating anti-GBM antibodies may be considered for renal transplantation.
[Efficacy criteria]
I. Cured Clinical symptoms disappear, hematuria and proteinuria are negative, and renal function is normal.
Improvement Clinical symptoms basically disappear, hematuria and proteinuria are significantly reduced, and renal function is close to normal.
Not cured Clinical symptoms are still obvious, hematuria and proteinuria persist, and renal function is abnormal.