Chronic kidney disease: stages, symptoms, recommendations. All about chronic renal failure: from symptoms to prevention Pathology leads to

Prevention

• balance the diet, give up fatty, smoked and spicy foods, reduce the intake of animal protein and salt;
• timely treat infectious diseases, especially diseases genitourinary system;
• reduce physical exercise, if possible, avoid psycho-emotional stress;

Acute renal failure (ARF) is a rapid, but reversible, depression of renal function, sometimes to the stage of complete failure of one or both organs. Pathology is deservedly characterized as a critical condition that requires immediate medical intervention. Otherwise, the risk of an unfavorable outcome in the form of a loss of organ efficiency increases greatly.

Acute renal failure

The kidneys are the main "filters" of the human body, the nephrons of which continuously pass blood through their membranes, removing excess fluid and toxins with urine, sending the necessary substances back into the bloodstream.

The kidneys are organs without which human life is impossible. Therefore, in a situation where, under the influence of provoking factors, they cease to fulfill their functional task, doctors provide a person with emergency medical care, diagnosing him with acute renal failure. Somatic pathology code according to ICD-10 - N17.

To date, statistical information makes it clear that the number of people facing this pathology is growing every year.

Etiology

The causes of djpybryjdtybz acute renal failure are as follows:

1. Pathologies of the cardiovascular system that disrupt the process of blood supply to all organs, including the kidneys:
   • arrhythmia;
   • atherosclerosis;
   • heart failure.
2. Dehydration against the background of the following ailments, which is the cause of changes in blood parameters, or rather, an increase in its prothrombin index, and, as a result, difficult work of the glomeruli:
   • dyspeptic syndrome;
   • extensive burns;
   • blood loss.
3. Anaphylactic shock accompanied by sharp decline indicators of blood pressure, which adversely affects the functioning of the kidneys.
4. Acute inflammatory phenomena in the kidneys, which lead to damage to organ tissues:
   • pyelonephritis.
5. physical obstruction to the flow of urine urolithiasis, which first leads to hydronephrosis, and then, due to pressure on the tissues of the kidneys, to damage to their tissues.
6. Taking nephrotoxic drugs, which include a contrast composition for x-rays, causes poisoning of the body, which the kidneys cannot cope with.

OPN classification

The process of acute kidney failure is divided into three types:

1. Prerenal acute renal failure - the cause of the disease is not directly related to the kidneys. The most popular example of the prerenal type of acute renal failure can be called disorders in the work of the heart, because the pathology is often called hemodynamic. Less often, it occurs against the background of dehydration.
2. Renal acute renal failure - the root cause of the pathology can be found in the kidneys themselves, and therefore the second name of the category is parenchymal. Renal functional insufficiency in most cases results from acute glomerulonephritis.
3. Postrenal acute renal failure (obstructive) is a form that occurs when the urinary excretion pathways are blocked by calculi and the subsequent violation of the outflow of urine.

Classification of acute renal failure


Pathogenesis

AKI develops over four periods, which always follow in this order:

• initial stage;
• oliguric stage;
• polyuric stage;
• recovery.

The duration of the first stage can last from several hours to several days, depending on what is the root cause of the disease.

Oliguria is a term that briefly refers to a decrease in the volume of urine. Normally, a person should allocate approximately the amount of fluid that he consumed, minus the part “spent” by the body on sweating and breathing. With oliguria, the volume of urine becomes less than half a liter, out of direct relation to the amount of fluid drunk, which entails an increase in fluid and decay products in the tissues of the body.

The complete disappearance of diuresis - happens only in extremely severe cases. And statistically it rarely happens.

The duration of the first stage depends on how quickly adequate treatment was started.

Polyuria, on the contrary, means an increase in diuresis, in other words, the amount of urine can reach five liters, although 2 liters of urine per day is already a reason for diagnosing polyuric syndrome. This stage lasts about 10 days, and its main danger is that the body loses the substances it needs along with urine, as well as dehydration.

After the completion of the polyuric stage, a person, with a favorable development of the situation, recovers. However, it is important to know that this period may be delayed for one year, during which deviations in the interpretation of the analyzes will be detected.

Stages of acute renal failure



Clinical picture

The initial stage of acute renal failure does not have specific symptoms by which the disease could be unmistakably recognized, the main complaints during this period are:

• loss of strength;
• headache.

The symptomatic picture is supplemented by signs of the pathology that caused acute renal failure:

1. With oliguric syndrome against the background of acute renal failure, the symptoms become specific, easily recognizable and fit into big picture pathologies:
   • decrease in diuresis;
   • dark foamy urine;
   • dyspepsia;
   • lethargy;
   • wheezing in the chest due to fluid in the lungs;
   • susceptibility to infections due to reduced immunity.
2. The polyuric (diuretic) stage is characterized by an increase in the amount of urine excreted, so all the patient's complaints stem from this fact, and the fact that the body loses a large amount of potassium and sodium with urine:
   • violations in the work of the heart are fixed;
   • hypotension.
3. The recovery period, which takes from 6 months to one year, is characterized by fatigue, changes in results laboratory research urine (specific gravity, erythrocytes, protein), blood (total protein, hemoglobin, ESR, urea,).

Diagnostics

Diagnosis of OPN is carried out using:

• questioning and examining the patient, compiling his anamnesis;
• a clinical blood test showing low hemoglobin;
• a biochemical blood test, which detects elevated creatinine, potassium, urea;
• diuresis monitoring, that is, control over how much liquid (including soups, fruits) a person consumes in 24 hours, and how much he excretes;
• the ultrasound method, with acute renal failure more often showing the physiological size of the kidneys, a decrease in size indicators is a bad sign, indicating tissue damage, which may be irreversible;
• nephrobiopsy - taking a piece of an organ with a long needle for microscopic examination; performed infrequently due to high degree trauma.

Treatment

Therapy of acute renal failure occurs in the intensive care unit of the hospital, less often in the nephrology department of the hospital.

All medical manipulations carried out by a doctor and medical staff can be divided into two stages:

1. Root Cause Identification pathological condition- carried out with diagnostic methods, the study of symptoms, specific complaints of the patient.
2. Eliminating the cause of acute renal failure is the most important stage of treatment, because without treating the root cause of the disease, any therapy will be ineffective:
   • when a negative effect of nephrotoxins on the kidneys is detected, extracorporeal hemocorrection is used;
   • when an autoimmune factor is detected, glucocorticosteroids (Prednisolone, Metipred, Prenisol) and plasmapheresis are prescribed.
   • in case of urolithiasis, medical litholysis or surgical intervention is performed to remove stones;
   • antibiotics are prescribed for infection.

At each stage, the doctor adjusts the appointment, based on the symptomatic picture at the moment.

During oliguria, it is necessary to prescribe diuretics, a strict diet with a minimum amount of protein and potassium, and, if necessary, hemodialysis.

Hemodialysis - a procedure for cleansing the blood of decay products and removing excess fluid from the body, has an ambiguous attitude from nephrologists. Some doctors argue that prophylactic hemodialysis for AKI is necessary in order to reduce the risk of complications. Other experts warn of a trend towards a complete loss of kidney function since the introduction of artificial blood purification.

During the period of polyuria, it is important to replenish the patient's missing blood volume, restore the electrolyte balance in the body, continue diet No. 4, and beware of any infection, especially when taking hormonal drugs.

General principles for the treatment of acute renal failure



Predictions and Complications

AKI against the background of proper treatment has a favorable prognosis: after the disease, only 2% of patients need lifelong hemodialysis.

Complications from acute kidney failure are associated with, that is, with the process of poisoning the body with its own decay products. As a result, the latter are not excreted by the kidneys with oliguria or with a low rate of blood filtration by glomeruli.

Pathology leads to:

• violation of cardiovascular activity;
• anemia;
• increased risk of infections;
• neurological disorders;
• dyspeptic disorders;
• uremic coma.

It is important to note that in acute nephrological insufficiency, in contrast to chronic, complications rarely occur.

Prevention

Prevention of OOP is as follows:

1. Avoid taking nephrotoxic drugs.
2. Timely treat chronic diseases of the urinary and vascular system.
3. Follow the metrics blood pressure, if signs of chronic hypertension are detected, immediately contact a specialist.

On the video about the causes, symptoms and treatment of acute kidney failure:


Markers of kidney damage are any changes detected during clinical and laboratory examination that are associated with the presence of pathological process in renal tissue (Table 1).

Table 1. Major markers of kidney injury suggestive of CKD

Marker	Remarks
Albuminuria/Proteinuria	Persistent increase in urinary albumin excretion greater than 10 mg/day (10 mg albumin/g creatinine) - see recommendation
Persistent changes in urine sediment	Erythrocyturia (hematuria), cylindruria, leukocyturia (pyuria),
Kidney changes in imaging studies	Anomalies in the development of the kidneys, cysts, hydronephrosis, changes in the size of the kidneys, etc.
Changes in the composition of blood and urine	Changes in serum and urinary concentrations of electrolytes, violations of acid-base balance, etc. diabetes insipidus and etc.)
Persistent decrease in glomerular filtration rate less than 60 ml / min / 1.73 sq.m	In the absence of other markers of kidney damage (see recommendation)
Pathological changes in the kidney tissue revealed during intravital nephrobiopsy	Should be taken into account, changes that undoubtedly indicate the "chronization" of the process (sclerotic changes in the kidneys, changes in membranes, etc.)

CKD is a supra-nosological concept, and at the same time it is not a formal association of chronic kidney damage of various nature.

The reasons for the allocation of this concept are based on the unity of the main pathogenetic mechanisms of the progression of the pathological process in the kidneys, the commonality of many risk factors for the development and progression of the disease in organ damage of various etiologies, and the resulting methods of primary and secondary prevention.

The diagnosis of CKD should be based on the following criteria:

1. The presence of any clinical markers of kidney damage, confirmed at least 3 months apart;
2. Any markers of irreversible structural changes organ identified once during intravital morphological examination of the organ or during its visualization;
3. Decreased glomerular filtration rate (GFR)< 60 мл/мин/1,73 кв.м в течение трех и более месяцев, вне зависимости от наличия других признаков повреждения почек.

In 2007 World Organization Healthcare (WHO) has significantly clarified the heading N18 (previously this code was "Chronic renal failure") of the international classifier of diseases (ICD-10). In order to preserve the generally accepted structure of the diagnosis, it is recommended that the diagnosis "Chronic kidney disease" be indicated after the underlying disease, and then the disease coding is set in accordance with the ICD for the underlying disease.

If the etiology of impaired renal function is unknown, then the main diagnosis may be "Chronic kidney disease", which is coded by heading N18 (where N18.1 - Chronic kidney disease, stage 1; N18.2 - Chronic kidney disease, stage 2, etc. ).

Stages of CKD	ICD-10 code (as amended by October 2007)**	Description of ICD-10
		CKD stage 1, kidney damage with normal or elevated GFR (>90 ml/min)
		CKD stage 2, kidney damage with slightly reduced GFR (60-89 ml/min)
		CKD stage 3, kidney damage with moderately reduced GFR (30-59 ml/min)
		CKD stage 4, kidney damage with a marked decrease in GFR (15-29 ml/min)
		CKD stage 5, chronic uremia, end stage kidney disease (including cases of RRT (dialysis and transplantation)

* - appropriate disease codes should be used to indicate the etiology of CKD

**- code N18.9 denotes cases of CKD with an unspecified stage

The need for early detection of CKD in children

Children have their own list of diseases that lead to the development of CKD:

1. Polycystic kidney disease or other genetic kidney disease in a family history.
2. Low weight at birth.
3. Acute renal failure as a result of perinatal hypoxemia or other acute kidney injury.
4. Renal dysplasia or hypoplasia.
5. Urological anomalies, especially obstructive uropathy.
6. Vesicoureteral reflux associated with repeated urinary tract infections and scarring of the kidneys.
7. Acute nephritis or a history of nephrotic syndrome.
8. Hemolytic-uremic syndrome in history.
9. Shenlein's disease - Henoch in history.
10. Diabetes.
11. Systemic lupus erythematosus.
12. Hypertension in history, in particular as a result of thrombosis of the renal artery or renal vein in the perinatal period.

Children with a lag in physical development (growth retardation, low body weight), rickets-like skeletal deformities, metabolic acidosis, early onset anemia, polyuria, polydipsia, proteinuria, hypertension, impaired renal concentration function represent a risk group for the development of CKD, which requires a thorough examination of these patients, the appointment of corrective and replacement therapy in order to prevent or slow down the progression of CKD.

Congenital, hereditary and acquired kidney diseases in children potentially carry the likelihood of developing adverse outcomes - the formation of chronic kidney disease (CKD) and CRF.

The need to identify CKD in children at an early stage is a socially significant task - the sooner we start preventing the identification of risk factors for developing CKD in children, the more people will remain healthy and able-bodied, while the risk of developing concomitant diseases will be significantly reduced.

Despite the possibilities modern medicine, about 40% of the pathologies of the urinary system over time leads to impaired renal function and the development of chronic renal (renal) insufficiency. This condition is characterized by the gradual death of nephrons, the deterioration of the body's vital functions and the appearance of various complications. How chronic renal failure develops, what symptoms it has, how it is diagnosed and treated: we will analyze in our review.

Acute and chronic progressive renal failure (code for international classification diseases ICD10-N17-N19) - a symptom complex in which the following occurs:

• violation of the processes of blood purification from metabolic products, toxins, nitrogenous bases, which are excreted by the kidneys;
• deterioration in the excretion of excess water and salts;
• a decrease or complete cessation of the production of erythropoietin by the kidneys, which is responsible for the activation of hematopoiesis;
• violation of homeostasis - the natural constancy of the internal environment.

Acute renal insufficiency (ICD-N17 code), with timely treatment, can result in a complete recovery of the patient. On average, it takes from 6 to 24 months to restore the functional activity of nephrons.

The diagnosis of chronic renal failure (ICD code - N18) is set while maintaining the laboratory criteria for the disease for 3 months or more. This pathology is characterized by an irreversible progressive course. However, regular courses of therapy will help maintain vital functions and avoid the development of life-threatening complications. Patients with chronic kidney disease who are treated live as long as people with healthy kidneys.

What diseases are complicated by kidney failure




It is important to understand that chronic (as well as acute) kidney failure is not a separate disease, but only a syndrome that complicates the course of many pathologies. Among the main causes of CKD are:

• chronic pyelonephritis;
• chronic glomerulonephritis;
• amyloidosis;
• polycystic kidney disease;
• congenital anomalies in the structure / functioning of the kidneys;
• urolithiasis;
• hydronephrosis;
• diseases associated with impaired physiological outflow of urine;
• nephrotoxic effect of certain drugs;
• diabetes;
• obesity;
• cirrhosis of the liver;
• gout;
• systemic diseases (scleroderma, lupus erythematosus);
• oncological diseases;
• chronic intoxication.

Note! The incidence of CRF in developed countries averages 600 cases per 1 million population.

Classification




There are several variants of chronic renal failure, and the classification of the disease is carried out according to:

• features of the clinical picture;
• severity.

Depending on the nature of the course, four stages of chronic renal failure are distinguished:

1. latent (hidden) - almost no clinical symptoms(with the exception of fatigue, general deterioration of well-being) and is often diagnosed incidentally during examination for another disease;
2. compensated stage of renal failure - characterized by a slight increase in urine output during the day (polyuria), swelling in the morning;
3. intermittent - accompanied by symptoms of intoxication (weakness, fatigue) and disturbances in the water-electrolyte balance (dry mouth, muscle weakness);
4. the terminal stage of chronic renal failure is accompanied by symptoms of uremia (poisoning by metabolic products) and pathology from the side internal organs, predominantly of the heart and lungs.

Laboratory criteria for assessing the severity of CRF are presented in the table below.

Clinical manifestations: how to suspect the disease at an early stage

Chronic renal failure is characterized by a wide variety of symptoms. This pathology affects all major organs and systems.

Appearance of the patient




For a long time, chronic renal failure, the symptoms and treatment of which largely depend on the stage of the disease, does not manifest itself in any way. External signs diseases can be detected only with severe uremia. Among the most common symptoms:

• pallor and severe dryness of the skin;
• hemorrhages and bruises that occur even with minimal exposure to the skin;
• scratching on the skin caused by severe itching;
• characteristic "renal" edema, manifested by puffiness of the face and eyelids, anasarca;
• decrease in muscle tone.

Urinary organs

On the initial stages disease, polyuria is observed - excretion a large number low density urine. In the future, with the progression of insufficiency, a partial or complete cessation of urine excretion develops.

Nervous system




Intoxication with metabolic products and substances toxic to the body leads to the following symptoms:

• lethargy;
• insomnia or, conversely, drowsiness during the day;
• memory impairment;
• decreased ability to learn;
• chilliness of the limbs;
• a feeling of tingling, "goosebumps" in the arms and legs.

In the terminal stage of the disease, there is a pronounced lethargy associated with the suppression of all functions of the central nervous system. If the patient is not given health care, serious disturbances are possible nervous system up to coma.

Heart and blood vessels




An increase in circulating blood volume and electrolyte disturbances lead to the following symptoms:

• increase in blood pressure;
• infectious and inflammatory lesions of the pericardial sac (myocarditis, pericarditis), accompanied by dull pain in the region of the heart, rhythm disturbances, shortness of breath, pathological pericardial friction noise during auscultation;
• sometimes - signs of acute cardiovascular insufficiency.

Respiratory system

Defeat respiratory system characteristic of late stages kidney failure. Patients develop a syndrome called "uremic lung". It is characterized by interstitial edema and bacterial pneumonia that develops against a background of reduced immunity.

Digestive system

The gastrointestinal tract reacts with a deterioration in appetite, nausea, and vomiting. Severe uremia is characterized by the development of erosive and ulcerative defects in the mucosa of the esophagus, stomach and intestines. It is not uncommon for patients with CKD to develop acute hepatitis.

Hematopoietic organs

Against the background of kidney failure, the production of erythropoietin, one of the factors of hematopoiesis, decreases. Clinically, this is manifested by symptoms of anemia - weakness, lethargy and decreased performance.

Water-electrolyte balance




Imbalance water-salt metabolism manifests itself:

• strong thirst;
• weakness (many patients complain that they get dark in their eyes with sudden changes in body position);
• convulsive muscle contractions;
• shortness of breath, respiratory disorders;
• arrhythmias.

Metabolism

In case of violations of the evacuation of protein metabolism products (creatinine, urea), the following symptoms appear in patients:

• toxic enterocolitis, accompanied by pain, bloating, liquid stool;
• the appearance of a characteristic ammonia odor from the mouth;
• secondary joint lesions mimicking gout.

Chronic renal failure is less common in children than in adults. characteristic feature clinical course pathology in a child is the frequent development of nephrotic syndrome - a massive excretion of protein in the urine (3 g / day and above), oncological edema and increased blood pressure.




A typical clinical picture with damage to the urinary system and other internal organs will make it possible to suspect chronic renal failure, and further diagnostics will be aimed at confirming or refuting this diagnosis. The standard algorithm for examining a patient with suspected CRF includes:

Collection of complaints and anamnesis. Clinical examination. Auscultation of the heart and lungs. Measurement of blood pressure. Laboratory tests.

• Clinical blood test;
• biochemical blood test with the determination of creatinine, urea, total protein;
• general urine analysis;
• urine sample according to Nechiporenko;
• urine sample according to Zimnitsky;
• Reberg's test;
• determination of glomerular filtration rate.
instrumental tests. According to indications. Ultrasound of the kidneys, excretory urography, rheovasography, and Doppler examination of the renal arteries are usually prescribed.

Diagnostic measures should be aimed not only at determining the severity of renal failure, but also at identifying its underlying cause. It is important for the doctor to identify the background of which disease developed CRF in order to correctly draw up a plan for its therapy.

Actual principles of treatment of chronic renal failure: is it possible to defeat the disease forever




Treatment of chronic renal failure always requires an integrated approach. It is aimed at restoring impaired functions of the urinary system, correcting electrolyte imbalance, preventing complications and eliminating symptoms.

An important role in therapy is played by nutrition correction. Diet in chronic renal failure can achieve good results and improve the prognosis of the disease. The principles of the treatment table according to Pevzner (renal) include:

• protein restriction to 60-70 g per day (with severe uremia, this figure is reduced to 20-40 g);
• the predominance in the diet of easily digestible animal protein, dairy and vegetable food;
• restriction of salt to 2-3 g per day;
• to correct electrolyte disturbances during diet therapy, it is recommended to consume more processed vegetables and fruits.

The drinking regimen for patients with chronic renal failure is set individually. They are generally advised to consume no more than 1.5-2 liters of fluid per day (including soups and other liquid foods).

Medical correction of the condition of patients consists in the appointment of:

• enterosorbents;
• erythropoietin;
• iron preparations;
• antihypertensive drugs;
• infusions with bicarbonate, glucose solution.

If the patient's condition worsens, hospitalization in the nephrology department of hospitals is indicated. In addition to drug therapy, the patient needs special care. Nursing Process in chronic renal failure includes providing:

• mental and physical rest;
• compliance with bed rest;
• accounting for water balance (the ratio of drunk and excreted fluid during the day);
• correct reception medicines patient.

In the terminal stage, the patient needs regular hemodialysis - blood purification using the "artificial kidney" apparatus.

CRF remains one of the leading problems in nephrology. The long progressive course and serious health consequences that the pathology causes make it dangerous for the patient. You can avoid the development of kidney failure if you regularly undergo examinations of the urinary organs and follow medical recommendations.

Symptoms of chronic renal failure are largely determined by the course of the underlying disease, however, regardless of the nosology that caused the development of glomerulosclerosis, chronic renal failure is characterized by changes in organs and systems due to exposure to toxic metabolic products. Currently, along with uremic toxins, more than 200 substances are known, the accumulation of which causes the progression of chronic renal failure.
Appearance does not suffer to the stage when glomerular filtration is significantly reduced.
Due to anemia, pallor appears, due to water and electrolyte disorders, dry skin.
As progression of the process appears yellowness of the skin and mucous membranes, reducing their elasticity.
Spontaneous hemorrhages and bruising may occur.
Scratching occurs due to itching of the skin.
Characterized by the so-called renal edema with puffiness of the face up to the common type of anasarca.
Muscles also lose their tone, become flabby, due to which fatigue increases and the patient's ability to work decreases.
Damage to the nervous system.
This is manifested by apathy, night sleep disorders and drowsiness during the day. Decreased memory, ability to learn. As chronic renal failure increases, pronounced lethargy and disorders of the ability to remember and think appear.
Violations in the peripheral part of the nervous system affect the chilliness of the limbs, tingling sensations, crawling. In the future, movement disorders in the arms and legs join.
urinary function.
She initially suffers from a type of polyuria (an increase in the volume of urine) with a predominance of nocturnal urination. Further, chronic renal failure develops along the path of reducing the volume of urine and the development of edematous syndrome up to total absence selection.
Water-salt balance.
Salt imbalance is manifested by increased thirst, dry mouth.
Weakness, darkening of the eyes when standing up abruptly (due to loss of sodium).
Excess potassium explains muscle paralysis.
Respiratory disorders.
Decreased heart rate, arrhythmias, intracardiac blockade up to cardiac arrest.
On the background increase in the production of parathyroid hormone by the parathyroid glands appears high level phosphorus and low level calcium in the blood. This leads to softening of the bones, spontaneous fractures, skin itching.
Nitrogen imbalances.
They cause an increase in blood creatinine, uric acid and urea, as a result of:
When GFR is less than 40 ml per minute, enterocolitis develops (damage to the small and large intestine with pain, swelling, and frequent loose stools).
Ammonia breath.
Secondary articular lesions of the type of gout.
The cardiovascular system.
First, it reacts with an increase in blood pressure.
Secondly, lesions of the heart (muscle - myocarditis, pericardial sac - pericarditis).
There are dull pains in the heart, heart rhythm disturbances, shortness of breath, swelling in the legs, enlarged liver.
With an unfavorable course of myocarditis, the patient may die on the background of acute heart failure.
Pericarditis can occur with the accumulation of fluid in the pericardial sac or the precipitation of uric acid crystals in it, which, in addition to pain and expansion of the boundaries of the heart, when listening chest gives a characteristic ("funeral") pericardial friction rub.
Hematopoiesis.
Against the background of a deficiency in the production of erythropoietin by the kidneys, hematopoiesis slows down. The result is anemia, which manifests itself very early in weakness, lethargy, and decreased performance.
Pulmonary complications.
Characteristic for the late stages of chronic renal failure. This is a uremic lung - interstitial edema and bacterial inflammation of the lung against the backdrop of a fall in immune defenses.
Digestive system.
It reacts with decreased appetite, nausea, vomiting, inflammation of the oral mucosa and salivary glands. With uremia, erosive and ulcerative defects of the stomach and intestines appear, fraught with bleeding (black feces appear). Acute hepatitis also becomes a frequent companion of uremia.