Chronic renal failure (CRF) is a syndrome consisting of various primary and secondary chronic kidney diseases resulting in decreased glomerular filtration rate and associated metabolic disorders and clinical symptoms.
Diagnosis
1, clinical manifestations of digestive system: common symptoms include nadir, nausea, vomiting, diarrhea and gastrointestinal bleeding and other manifestations. Gastrointestinal symptoms are the early clinical manifestations of chronic renal failure, and become increasingly prominent with the development of the disease, and can become very serious in the later stages, often becoming one of the important complaints when patients visit the clinic.
(1) Cardiovascular system: damage to the cardiovascular system is very common in uremic patients and is one of the important causes of death in patients with chronic renal failure. It mainly includes pericarditis, cardiomyopathy, endomyopathy, heart failure and hypertension, etc. Cardiac insufficiency is the main cause of death in patients with chronic renal failure.
(2) Respiratory system: The primary problem is lung infection. Pulmonary infections are one of the main causes of death in patients with chronic renal failure. Lung infections mainly include pneumonia, bronchopneumonia, bronchiectasis, 60% to 70% of which are Gram-negative bacillary infections, which can develop into serious infections if not treated in time. In addition, viral, fungal, and tuberculosis infections can also be seen. Next, it is often complicated by uremic lung and uremic pleurisy.
(3) Hematopoietic system: anemia is one of the important clinical manifestations in patients with chronic renal failure, and the clinical symptoms are milder than other kinds of chronic anemia, and the tolerance to anemia is much stronger than that of normal people. Although the anemia is more severe, there are mostly no obvious palpitations, shortness of breath, chest tightness, accelerated heart rate and other manifestations. Patients often have significant bleeding tendency and bleeding manifestations. Patients with chronic renal failure are prone to infection due to impaired granulocyte and lymphocyte function, which becomes the main cause of death in acute and chronic renal failure.
Renal bone disease, for the most part, is divided into three types: high-running, low-running, and mixed types. Clinically, bone pain, fracture and bone deformation are the main symptoms, but there may also be muscle and joint symptoms, muscle atrophy, periarthritis and aseptic necrosis of the femoral head.
(1) Neurological and muscular system: mainly fatigue, weakness, head weight, memory loss, concentration difficulties, irritability and self-consciousness, reduced calculation and work efficiency, insomnia, dreaminess and change in sleep patterns. In the late stage, there are drowsiness, expressions, and other symptoms. In the late stage, there is drowsiness, indifference, incontinence, and gradually enter coma. Muscle lesions mainly manifest as muscle weakness, painful muscle spasms, muscle tremors, muscle atrophy, and erratic rebellion.
(2) Endocrine function: Insufficient secretion of hormones produced by the kidneys, such as decreased erythropoietin production leading to renal anemia, 1,25(OH)2D3 deficiency leading to renal bone disease; reduced ability of the kidneys to degrade and clear some hormones in the body; uremia can cause target tissue resistance to certain hormone effects, such as insulin due to impaired renal clearance, prolonged half-life and elevated plasma levels, but the patient still shows typical Glucose intolerance, the main reason for which is due to impaired insulin target tissue response.
(3) Thyroid and gonadal dysfunction: symptoms such as fatigue, cold, drowsiness, slow thinking, false swelling, dry skin, and hypoactive nerve reflexes are often seen. Men show reduced libido, impotence, shrunken testes, reduced sperm count and poor motility, reduced plasma total testosterone levels, and enlarged breasts in some patients. In women, the symptoms include altered menstrual cycle or menopause, decreased menstrual flow, decreased fertility, increased infertility and miscarriage and premature birth.
(4) Abnormal lipid metabolism: The abnormalities of lipid metabolism in patients with chronic renal failure are mainly seen in triglycerides (TG), very low density lipoproteins (VLDL), low density lipoproteins (LDL) and apolipoprotein C II (apo-C II) and apolipoprotein C III (apo-C III), especially in VLDL, which is significantly elevated. VLDL is particularly elevated.
(5) Water-electrolyte disorders: In the early stage of chronic renal failure, polyuria or nocturia occurs, and oliguria or anuria is a serious late stage manifestation. Water metabolism disorder is manifested as water overload or water loss. Edema, heart failure and hypertension appear when sodium load is increased. Excessive restriction of sodium intake tends to lead to hyponatremia. Late oliguria and increased blood sodium can lead to acute hypernatremia if accompanied by high sodium food intake or excessive sodium bicarbonate input. Blood potassium is often elevated in the late stages of chronic renal failure. Hypokalemia is rare in chronic renal failure. Hypocalcemia and hyperphosphatemia are common in chronic renal failure.
(6) Acid-base imbalance imbalance: mainly metabolic acidosis. In the early stage, there is fatigue, anorexia, nausea, deepening of respiration, etc.; in severe cases, it is manifested as deep breathing, confusion, and even myocardial contraction weakness, abnormal conduction and death.
2, auxiliary examination of renal function: GFR decreases in the early stage, and blood creatinine and urea nitrogen rise in the middle and late stage. Blood creatinine and urea chloride are common indicators of renal function examination, but in the early stage of renal function damage, they usually do not show abnormalities. At this time, eGFR should be calculated, or 24-hour urine should be kept, and endogenous creatinine clearance should be calculated by assaying urine creatinine liver, combined with blood creatinine, for early detection of renal insufficiency. Blood α, β2-microglobulin, blood urine osmolality, etc. are also important for early diagnosis of renal insufficiency.
(1) Blood routine: anemia, mostly nonproliferative, normocytic orthochromic anemia, a few small-cell hypochromic or large-cell orthochromic due to blood loss, malnutrition and gastrointestinal lesions. Reticulocytes are mostly normal or slightly elevated. Bone marrow nucleated cells are normal or show hyperplasia.
(2) Other: elevated blood potassium, high phosphorus and low calcium, decreased blood HCO3, ultrasound examination of the kidneys: both kidneys are shrunken. Radiographic nephrograms, renal blood flow, etc. are also helpful.
3.Diagnostic criteria.
(1) Chronic kidney disease for more than 3 months.
(2) Glomerular filtration rate (GFR) below 60 ml/min/1.73m2 for at least 3 months (below 50 ml/min in the elderly)
(3) Metabolic disorders and clinical symptoms associated with renal failure during the decline in glomerular filtration rate.
The above 3 articles, the first article is the main basis for diagnosis, according to the second article diagnosis should be cautious or strictly grasp. If the third article is available at the same time, the diagnosis will be based more fully. Detailed medical history, careful physical examination and necessary laboratory tests should be conducted to raise the vigilance of chronic renal failure in order to avoid misdiagnosis.
4.Differential diagnosis
(1) Differentiation between CRF and pre-renal azotemia: renal function can be restored in patients with pre-renal azotemia after 24-72 hours of effective blood volume replenishment, while renal function is difficult to be restored in CRF.
(2) Differentiation of CRF from acute renal failure: The differentiation is often made based on the patient’s medical history. When the patient’s medical history is not detailed, the diagnosis of CRF can be analyzed with the help of imaging examinations (such as ultrasound, CT, etc.) or nephrographic findings, if both kidneys are significantly reduced, or if the nephrographic findings suggest chronic lesions, the diagnosis of CRF is supported.
(3) Chronic renal failure with acute renal failure: If chronic renal failure is mild and acute renal failure is relatively prominent, and its course is consistent with the evolution of acute renal failure, it can be called chronic renal failure combined with acute renal failure, and its management principles are basically the same as those of acute renal failure. If the chronic renal failure itself is relatively severe, or its course of aggravation does not reflect the evolution of acute renal failure, then it is called acute exacerbation of chronic renal failure.
Treatment
Chinese medicine treatment of chronic renal failure in the early stage is mostly Chinese medicine qi deficiency, blood stasis, dampness and turbidity evidence treatment: benefit qi and blood, dampness and turbidity prescription: Yi kidney slow decline formula plus reduction. The medicine includes 15g of Astragalus membranaceus, 10g of Atractylodes macrocephala, 15g of Radix Angelicae Sinensis, 15g of Radix Paeoniae Alba, 15g of Radix Paeoniae Alba, 15g of Rhizoma Ligustici Chuanxiong, 12g of Radix et Rhizoma Polygonati, 15g of Radix et Rhizoma prunus, 15g of Radix Huo Stem, 15g of Radix Su Stem, 9g of Rhizoma Polygonati, 20g of Ochre (decoction first), 9g of Radix Panax, 10g of Chen Pi.
Commonly used traditional Chinese medicine: Bai Ling capsule or Jin Shui Bao capsule: 4-6 capsules each time, 3 times a day.
Chronic renal failure in the middle and late stages mostly belongs to the Chinese medicine Qi deficiency, dampness and heat in the obstruction of the evidence of treatment: benefit the Qi to strengthen the spleen, clear heat and dampness, and harmonize the stomach to stop vomiting.
The formula: qi deficiency is the main, fragrant sand six junzi plus or minus, the medicine with party ginseng 10g, astragalus 15g, atractylodes 10g, poria 15g, muxiang 9g, sand 9g, coix seeds 20g, parasitic 12g, jiao rhubarb 9g. damp heat contains turbidity, blocking the qi, the three jiao pivot is unfavorable, available small Chaihu Tang plus or minus treatment, the medicine with Chaihu 10g, scutellaria 15g, Huanglian 6g, Jiang Hanxia 9g, Chen Pi 9g. It can also be treated with Han Xia Di Xuan Xin Tang with addition and subtraction.