Chronic renal insufficiency

　　The main etiologies include primary glomerulonephritis, chronic pyelonephritis, hypertensive renal arteriosclerosis, diabetic nephropathy, secondary glomerulonephritis, tubulointerstitial lesions, hereditary kidney diseases, and long-term use of antipyretic and analgesic agents, as well as contact with heavy metals, and others.

　　1. It is necessary to strive to clarify the etiology of chronic renal failure, and it is necessary to understand whether the renal damage is mainly due to glomerular damage, interstitial tubular lesions, or prominent renal vascular lesions, so as to treat it according to the clinical characteristics.

　　2. It is necessary to investigate the reversible factors that promote the progressive deterioration of renal function in chronic renal failure, such as infection, drug-induced renal damage, metabolic acidosis, dehydration, heart failure, rapid and low blood pressure, and others.

　　3. It is necessary to find certain factors that may exacerbate the progressive deterioration of renal function in chronic renal failure, such as hypertension, hyperlipidemia, hypercoagulability, high protein diet intake, and large amounts of proteinuria.

　　Common complications include hypertension, anemia, heart failure, pericarditis, cardiomyopathy, water and electrolyte imbalance, acid-base imbalance, renal osteodystrophy, fractures, infections, and others.

　　In addition to the above systemic complications, long-term dialysis patients with chronic renal insufficiency can also have the following complications:

　　Aluminum poisoning

　　End-stage renal disease patients receiving routine dialysis treatment are prone to aluminum poisoning.

　　Dialysis-related amyloidosis

　　Dialysis-related amyloidosis (DRA) is a bone and joint disease seen in long-term dialysis patients. Its clinical symptoms and incidence are closely related to the duration of dialysis.

　　3. Changes in trace elements

　　Renal failure and dialysis have a great impact on the metabolism of trace elements. They accumulate in various parts of the body and can cause toxic reactions.

　　1. Aluminum: See aluminum poisoning.

　　2. Copper: The plasma copper levels of patients with chronic renal failure who have not undergone dialysis are often normal, but can also be slightly low.

　　3. Zinc: The plasma zinc content is often very low in patients with chronic renal failure who consume a low-protein diet or have a large amount of urinary protein loss due to nephrotic syndrome.

　　1. First stage of renal insufficiency:In the compensatory stage of renal insufficiency, the blood creatinine (Scr) is between 133 and 177 umol/L. Due to the large compensatory capacity of the kidneys, although the renal function has decreased clinically, the kidney's ability to excrete metabolic products and regulate water and electrolyte balance can still meet normal needs, and there are no symptoms in clinical practice, and renal function tests are within the normal range or occasionally slightly elevated.

　　2. Second stage of renal insufficiency:The decompensated stage of renal insufficiency (also known as the nitrogenous stage of renal insufficiency), the blood creatinine (Scr) is between 177 and 443 umol/L, with an increase in the number of glomerulosclerosis and fibrosis, about 60% to 75% of the damage, and there is already some obstruction in the kidney's excretion of metabolic waste, with elevated blood creatinine and blood urea nitrogen, or exceeding the normal value. Patients may experience anemia, fatigue, weight loss, and difficulty concentrating, but these are often overlooked. If there are conditions such as dehydration, infection, or bleeding, the progression of the disease will accelerate.

　　3. Third stage of renal insufficiency:In the stage of renal failure, the blood creatinine (Scr) is between 443 and 707 umol/L, with glomerulosclerosis, tubulointerstitial fibrosis, and renal vascular fibrosis, leading to severe kidney function damage, marked anemia, increased nocturia, and significant increases in blood creatinine and blood urea nitrogen. There is often acidosis, and without systematic and regular treatment, it will develop into end-stage renal disease, which is more difficult to treat.

　　4. Fourth stage of renal insufficiency:In the stage of uremia or the terminal stage of renal insufficiency, the blood creatinine (Scr) is above 707 umol/L. Patients in the uremic stage of renal insufficiency have more than 95% glomerular damage, with severe clinical symptoms, such as severe nausea and vomiting, oliguria, edema, malignant hypertension, severe anemia, pruritus, a smelly taste in the mouth, etc.

　　1. It is necessary to have a reasonable intake of protein. The metabolic products in the human body mainly come from the protein components in the diet, therefore, in order to reduce the workload of the remaining kidneys, the protein intake must be adapted to the kidney's excretion capacity. For example, when the blood creatinine level is between 170 to 440 micromoles per liter, it is advisable to have 0.6 grams of protein per kilogram of body weight per day, and for those with a large amount of proteinuria, for every 1 gram of urinary protein lost, an additional 1.5 grams of protein can be supplemented. When the blood creatinine level exceeds 440 micromoles per liter, the protein intake should be further reduced, and it is better to not exceed a total of 30 grams per day. However, it must be emphasized that if one excessively pursues limiting protein intake, it will lead to malnutrition, decline in physical condition, and is not effective.

　　2. In order to maximize the utilization of ingested protein and prevent its conversion into energy that is consumed, while adopting a low-protein diet, it is also necessary to supplement energy. At least 35 calories per kilogram of body weight per day are required, mainly provided by sugar, and fruits, sugar products, chocolate, jam, honey, etc., can be eaten.

　　3. It is noteworthy that some foods, although meeting the previous conditions, such as egg yolks, meat floss, animal internal organs, dairy products, bone marrow, etc., are not suitable for consumption due to their high phosphorus content. Because the retention of phosphorus can promote the further deterioration of kidney function. To reduce the phosphorus content in food, fish, meat, potatoes, etc., should be boiled in water and the soup discarded before further cooking.

　　4. The amount of salt should be determined according to the condition, and for those with hypertension and edema, a low-salt diet should be adopted, with 2 grams of salt per day.

　　5. Drugs excreted by the kidneys may also damage the kidneys, such as gentamicin, sulfonamide antibiotics, penicillin, indomethacin, paracetamol, as well as hormones, contrast agents, etc.

　　Firstly, laboratory tests

　　1. Urine examination

　　The urine routine protein level is generally greater than 2.0 g/L, and the urine protein level decreases as kidney function damage becomes obvious in the late stage. The specific gravity of morning urine decreases to below 1.018, or remains fixed at about 1.010.

　　Since anemia is present in all stages of chronic renal failure, routine blood tests are important for the diagnosis of chronic renal failure. Other tests include determination of plasma total protein, albumin, globulin, and their ratios; determination of blood electrolyte levels (HCO3-, K, Na, Ca, Mg2+, P3, etc.).

　　Serum creatinine (Scr) and blood urea nitrogen (BUN) levels rise, and the determination of urine concentration and dilution function suggests a decrease in the内生肌酐清除率 (Ccr).

　　2. Liver function and hepatitis B two pairs and half examination

　　3. Serum immunology examination

　　Including serum IgA, IgM, IgG, complement C3, complement C4, T lymphocyte subsets, B lymphocyte subsets CD4/CD8 ratio, etc.

　　4. Nutritional status indicators detection

　　Determine the levels of serum total protein, serum albumin, serum transferrin, and low molecular weight protein. Extremely low levels of cholesterol are also considered as indicators of malnutrition.

　　Secondly, imaging examinations

　　1. Renal ultrasound

　　The thickness of the renal cortex is less than 1.5 cm, which is better than using kidney size as a standard to judge chronic renal failure. If both kidneys atrophy, it supports the diagnosis of end-stage disease.

　　2. Other

　　Routine electrocardiogram, X-ray chest film, bone film, and gastroscopy, as well as certain special examinations such as X-ray contrast, radionuclide renal scan, CT, and magnetic resonance, are helpful in determining the shape, size, and the presence of urinary tract obstruction, hydronephrosis, calculi, cysts, and tumors of the kidneys.

　　In terms of diet, it should be regular and reasonable, that is, to take high-protein, high-vitamin foods as the mainstay. Choose high-nutritional value plant or animal proteins, such as milk, eggs, fish, lean meat, various soy products, etc. Various fresh vegetables and fruits are rich in vitamins and have high nutritional value.

　　First, Treatment of the Etiology

　　Such as prevention and treatment of infection, correction of water and electrolyte disorders, and so on.

　　Second, Reduce Azotemia

　　1. High sugar diet or high-quality low-protein diet from the vein, that is, to take a small amount of poultry eggs, milk every day, supplemented with meat and fish;

　　2. Nandrolone phenylpropionate 25 milligrams, injected intramuscularly every other day or twice a week to increase protein synthesis;

　　3. Promote the excretion of nitrogenous products, mainly through diuresis with intravenous injection of furosemide (Lasix), artificial kidney dialysis methods, generally about 12-24 hours per week.

　　Third, Correct Water, Electrolyte, and Acid-Base Metabolic Imbalance

　　1. Water: generally, there is no need to limit water intake; in cases of severe dehydration, intravenous infusion should be used to supplement; in cases of edema, diuresis should be used to drain water;

　　2. Sodium: generally, there is no need to limit salt intake for patients; in cases of low blood sodium, appropriate intravenous supplementation should be made; in cases of high blood sodium, a low-salt or salt-free diet should be adopted, and diuresis should be promoted to promote excretion;

　　3. Calcium and phosphorus: take 20-30 milliliters of aluminum hydroxide gel orally, four times a day, to inhibit the absorption of phosphorus in the intestines; take calcium supplements to supplement calcium concentration;

　　4. Correct metabolic acidosis: intravenous infusion of 100-300 milliliters of 5% sodium bicarbonate or 300-500 milliliters of 1.8% sodium lactate.

　　Fourth, Symptomatic Treatment

　　If nausea and vomiting are treated with methoxyphenylpiperazine (antiemetic), chlorpromazine, and other drugs; hiccups can be treated with atropine or acupuncture; significant diarrhea can be treated with Compound Camphor Tincture; agitation and convulsions can be treated with diazepam (Valium) or chlorpromazine; high blood pressure, arrhythmia, cardiac insufficiency, and other conditions should refer to the respective diseases.

　　Fifth, Kidney Transplantation Treatment

　　Kidney transplantation is limited to uremic patients under the age of 50 and is currently the best treatment method for uremia, with the longest survival period of nearly 30 years.