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Comprehensive treatment of nephrotic syndrome

Dec 31, 2016
(1) primary treatment (suppression of immune and inflammatory responses)
1 glucocorticoid treatment of glucocorticoid for kidney disease, mainly its anti-inflammatory effect. It can relieve acute inflammation exudation, lysosomal membrane stability, reduce the deposition of fibrin, reduce capillary permeability and reduce urinary protein leakage; in addition, can inhibit the proliferative response in chronic inflammation, reduce fibroblast activity, reduce tissue repair and fibrosis. The effect of glucocorticoids on the response to a large extent depends on the type of Pathology, it is generally considered that only the most effective micro lesions.
Hormone preparations have short effect (half-life 6 ~ 12 hours): prednisone (20mg); the effect of (12 to 36 hours): prednisone (5mg), P Nixonn Ron (5mg), Kap Nixonn Ron (4mg), f-oh P Nixonn Ron (4mg); long term (48 to 72 hours): dexamethasone (0.75mg) Batamison, (0.60mg). Hormones can be quickly absorbed by the gastrointestinal tract, so the tablet is the most commonly used dosage form. The first dose of prednisone for treatment of general 1mg/ (kg - D), children of 1.5 ~ 2mg/ (kg - D). After 8 weeks of treatment, the effective application should be maintained, then gradually reduced, generally every 1 to 2 weeks Jianyuan dose of 10% ~ 20%, the less dose decreasing less, slower. The maintenance and maintenance time of hormone were different in different cases, and the minimum dosage was not to appear clinical symptoms, which was lower than 15mg/d. Adjust the dosage of hormone during the maintenance phase, such as body weight change, infection, surgery and pregnancy. After more than 8 weeks of formal treatment of invalid cases, the need to exclude the impact of factors, such as infection, edema caused by weight gain and renal vein thrombosis, etc., should be timely diagnosis and treatment. The oral steroid treatment of adverse reactions, severe edema effect on the absorption of gastrointestinal hormone, systemic diseases (such as systemic lupus erythematosus) this serious disease caused; obvious renal interstitial lesions, small diffuse hyperplasia, crescent formation and vascular fibrinoid necrosis patients, can be intravenous glucocorticoid shock treatment. The dose of methylprednisolone pulse therapy for 0.5 ~ 1g/d, 3 ~ 5 days of treatment, but according to clinical experience, generally used in small doses of prednisolone, namely 240 ~ 480mg/d, 3 ~ 5 days of treatment, after 1 weeks to oral dose. In this way, it can reduce the side effects caused by the high dose of hormone shock, and the clinical effect is not affected. The corresponding dose of dexamethasone for 30 ~ 70mg/d, but should pay attention to add water sodium retention and hypertension and other side effects. Long term use of hormones can produce many side effects, sometimes very serious. The high level of protein decomposition induced by hormones can aggravate the blood stasis, promote the increase of serum uric acid, induce gout and aggravate the decline of renal function. High dose therapy can sometimes exacerbate hypertension and promote heart failure. The symptoms of infection can not be obvious when using hormone, which is easy to delay the diagnosis. Long term use can exacerbate this hormone bone disease, and even produce aseptic femoral neck necrosis.
2 cytotoxic drug hormone treatment is invalid, or hormone dependent or recurrent type, due to the side effects of hormone intolerance can not continue to use the drug can be used in the treatment of cytotoxic drugs. Because of the toxicity of these drugs, such as gonadal toxicity, reduce the body's resistance and induce tumor risk, therefore, should be carefully controlled in medication indications and treatment. If the focal segmental glomerulonephritis is very bad for the cytotoxic drugs, it should not be used. At present, the most commonly used drugs in clinical practice, cyclophosphamide (CTX) and nitrogen (CB1348) are the most reliable. The dose of CTX was 2 ~ 3mg/ (kg = D), and the course of treatment lasted for a period of 8 weeks. When the total amount was more than 300mg/kg, it was easy to produce the toxicity. 0.1mg/ (kg = D) was orally administered in 3 times for a period of up to 8 weeks, and the cumulative effect of the total amount reached to 7 ~ 8mg/kg. Relapse and relapse after medication do not advocate for the second medication, so as not to poisoning. The syndrome of lupus nephritis, membranous nephritis, advocate using CTX pulse therapy, the dose of 12mg ~ 20mg/ (kg times), once a week, for 5 to 6 times, according to the tolerance of patients after prolonged treatment periods, the total dose was 9 ~ 12g. The aim of the treatment is to reduce the dosage of hormone, reduce the complications and improve the curative effect.
3 cyclosporine A (CyA) CyA is an effective immunosuppressive agent, which has been used in the treatment of various autoimmune diseases in recent years. At present, the clinical effect of small lesions and proliferative glomerulonephritis is more positive. Compared with hormones and cytotoxic drugs, the greatest advantage of using CyA is to reduce proteinuria and improve the efficacy of hypoproteinemia reliable, does not affect the growth and inhibition of hematopoietic function. However, the drug also has a variety of side effects, the most serious side effects of kidney and liver toxicity. The incidence of nephrotoxicity is 20% ~ 40%, and the long-term application can lead to interstitial fibrosis. Inpidual cases relapse after stopping drug. So it is not appropriate to use this drug for the treatment of Shenbing syndrome, it is not easy to take this medicine as the first choice drug. The CyA dose was 3 ~ 5mg/ (kg - D), the blood drug concentration of the valley in 75 ~ 200 g/ml (blood, HPLC), generally after 2 ~ 8 weeks of onset, but inpidual differences, inpidual patients need longer time to be effective, effective should be gradually reduced. The rise of serum creatinine in the course of medication should be alert to the possibility of CyA poisoning. The course of treatment is generally 3 to 6 months, recurrence can be effective.
4 comprehensive treatment of traditional Chinese medicine because of some patients on immunosuppressive treatment response is not good, continue to lose a lot of protein from urine. For these patients in addition to symptomatic treatment, you can try Chinese medicine treatment. According to the theory of traditional Chinese medicine, in edema, mainly for the spleen kidney two empty and Tianjin water accumulated in the interstitium, in the virtual reality of the performance, so the treatment should be supplementation and attack, which is based on the diuretic of warming kidney and invigorating spleen on the swelling. Syndrome differentiation: spleen kidney yang deficiency, treatment with temperature Shenshi spleen, and for the benefit of water. Prescription drugs available Zhenwu Decoction, Jisheng Shenqi pill. The spleen and kidney deficiency type: treatment for Yiqi Jianpi Wenshen decoction, spleen decoction or available Fangji Fuling Decoction and SHENLINGBAISHU decoction. The kidney yin deficiency: treatment for nourishing yin and Yang, prescription available Jisheng Shenqi pills, glutinous rehmannia.
(two) symptomatic treatment
1 treatment with low serum albumin
(1) dietary therapy: patients are usually negative nitrogen balance, if you can eat a high protein diet, it is possible to turn into positive nitrogen balance. However, patients with high protein intake will lead to increased urinary protein, increased glomerular damage, while plasma albumin levels did not increase. Therefore, the recommended daily intake of 1g/kg protein, plus daily urine lost within the protein quality, each intake of 1G protein, non protein calorie intake must be at the same time, 138kJ (33kcal). The supply of protein should be high quality protein, such as milk, eggs and fish, meat.
(2) intravenous albumin: intravenous infusion of albumin in the urine within 1 to 2 days, which is lost from the urine, and expensive. In addition a large number of intravenous albumin induced immunosuppression, hepatitis C, heart failure, delayed remission and increase the recurrence rate and other side effects, therefore, strict indications should be in the application of intravenous albumin: when severe systemic edema, and intravenous injection of furosemide can not achieve the diuretic effect of patients in the intravenous infusion of albumin, followed by intravenous infusion of furosemide (Lasix 120mg, adding glucose solution 100 ~ 250ml, slow infusion of 1 hours), often can make the original of furosemide invalid can still get a good diuretic effect. The use of furosemide diuresis, plasma volume insufficient clinical manifestations. Acute renal failure due to renal interstitial edema.
2 treatment of edema
(1) sodium restricted diet: edema itself suggests excessive sodium in the body, so it is important to limit the intake of salt. The normal daily intake of salt is 10g (containing 3.9G sodium), but because patients often due to sodium restriction after eating tasteless and loss of appetite, affect the intake of protein and calorie. Therefore, the sodium restricted diet should be able to tolerate the patient, does not affect their appetite for the degree, low salt diet salt content of 3 ~ 5g/d. Chronic patients, due to long-term sodium restricted diet, can lead to intracellular sodium deficiency, should pay attention to.
(2) the use of diuretics: according to different sites, diuretics can be pided into: main loop diuretics inhibit the medullary ascending limb of chloride and sodium reabsorption, such as furosemide (Lasix) and bumetanide Ying (Ding Niaoan) as the most powerful diuretic. The dose of furosemide and bumetanide 20 ~ 120mg/d, 1 ~ 5mg/d. The thiazide diuretics: a major role in the me dullary thick ascending branch of loop segment (cortex) and distal tubule segment, through reabsorption inhibition of sodium and chlorine, increased potassium excretion and achieve a diuretic effect. The common dosage of hydrochlorothiazide is 75 ~ 100mg/d. The excretion of sodium retention of potassium diuretics: a major role in the distal tubule and collecting duct, for aldosterone antagonists. The usual dose of spironolactone was 60 ~ 120mg/d, the use of such drugs is poor effect alone, so often and excretion of potassium diuretic. The permeability of the glomerular filtration by diuretics: free without tubular reabsorption, thereby increasing the osmotic concentration of the tubules, prevent the proximal tubule and distal tubule reabsorption of sodium and water, in order to achieve the diuretic effect. The usual dose of low molecular dextran 500Ml/2 ~ 3D, mannitol 250Ml/d, pay attention to renal damage with caution. The preferred drug for patients with diuretic furosemide dose, but inpidual differences; good effect of intravenous medication methods: 100mg furosemide add 100Ml glucose solution or 100ml mannitol, slow intravenous infusion for 1 hours; furosemide excretion of potassium diuretic, spironolactone combined with so often. Long term application of furosemide (7 ~ 10 days) after the diuretic effect is reduced, sometimes with the best dose, to stop drug clearance medication for 3 days before. It is suggested that diuretics should be used in combination with different action sites for severe edema.
3 high coagulation therapy
Patients with coagulation factors in the blood hypercoagulability, especially when the plasma albumin is lower than 20 ~ 25g/L, that is, the possibility of venous thrombosis. At present, the commonly used anticoagulant drugs:
(1): heparin by activating antithrombin III (AT III) activity. The dose of 50 75mg/d was used to make the active unit of AT. It is reported that heparin can reduce proteinuria and improve renal function, but its mechanism is not clear. It is noteworthy that heparin (MW65600) can cause platelet aggregation. At present, there are small molecular weight heparin subcutaneous injection, once a day.
(2) urokinase (UK): direct activation of plasminogen, leading to fibrinolysis. The usual dosage is 2 ~ 80 thousand U/d, which is used in small doses and can be used simultaneously with heparin. Objective to monitor the lysis time of globulin in 90 to 120 minutes. The main side effects of UK are allergies and bleeding.
(3) warfarin: inhibit the synthesis of vitamin K in the liver cells dependent factor II, VII, IX, X, commonly used dose of 2.5mg/d orally, monitoring of prothrombin time in the normal 50% ~ 70%.
(4) Pan Shengding: platelet antagonists, the usual dose of 100 ~ 200mg/d. In general the hypercoagulable state of intravenous anticoagulation for 2 to 8 weeks, then changed into warfarin or oral dipyridamole.
A venous thrombosis: surgical removal of thrombus. Interventional thrombolysis. The method of interventional radiology was used to dissolve the renal vein thrombosis by injecting UK24 U into the renal artery. Systemic venous anticoagulation. Heparin plus urokinase for 2 to 3 months. The oral warfarin to hit remission to prevent thrombosis formation.
4 hyperlipidemia treatment
Patients, especially those with multiple relapses, had a long duration of hyperlipidemia, and even after remission, hyperlipidemia persisted. In recent years, to realize the effects of hyperlipidemia on the progression of renal disease, and disease medicine such as glucocorticoid and diuretic, can aggravate hyperlipidemia, so at present advocate the use of lipid-lowering drugs on hyperlipidemia. Can choose the lipid-lowering drugs: fibric acid (fibric acids): fenofibrate (fenofibrate) 3 times daily, 100mg each time, gemifibrozil (gemfibrozil) 2 times daily, 600mg each time, the blood triglyceride cholesterol lowering effect is stronger than. This medicine with gastrointestinal discomfort and serum transaminases. The Hmg-CoA reductase inhibitor lovastatin (MEVACOR), 20mgBid (Shu Jiangzhi), 5mg, simvastatin Bid; these drugs mainly intracellular Ch decreased, reduce the concentration of plasma LDL-Ch, VLDL and LDL have reduced liver cells. The angiotensin converting enzyme inhibitor (ACEI): the main role of Ch has been decreased and the concentration of TG in plasma; the plasma HDL increased, and the major apolipoprotein ApoA- I and ApoA- II increased, can accelerate the removal of surrounding tissue in Ch; reduce LDL infiltration of the intima, protect the arterial wall. ACEI also have different degrees of decrease proteinuria excretion.
5 acute renal failure treatment
Treatment of acute renal failure due to different causes. The main principles of treatment for patients with hemodynamic factors include: rational use of diuretics, corticosteroids, correct low blood volume, and dialysis therapy. Hemodialysis is not only to control the quality of blood stasis, maintain electrolyte acid-base balance, and can quickly remove water retention. Acute renal failure due to interstitial edema of the kidney, the renal function recovered quickly after the treatment. Need to pay attention to the use of diuretics: the timely use of diuretics: with acute renal failure and severe hypoproteinemia, without the supplement of plasma protein using large dose of diuretics, will aggravate hypoproteinemia and low blood volume, worsening renal failure. It should be added after the plasma albumin (daily intravenous 10 ~ 50g human albumin) and then diuretic. However, if an excess of plasma albumin is not used in time, it may lead to pulmonary edema. Appropriate use of diuretics: as a result of patients with a relative lack of blood volume and low blood pressure tendency, at this time should be diuretic with daily urine volume of 2000 to 2500ml or weight loss of about 1kg per day is appropriate. Patients with elevated plasma renin levels, the use of diuretics decreased blood volume after the plasma renin level is higher, diuretic treatment is not only ineffective but worse condition. This kind of patients only after correction of hypoproteinemia and low blood volume and then diuretic is beneficial to the recovery of renal function.
Combined with acute renal failure, most of them were reversible, and most of the patients recovered gradually with the increase of urine volume. A small number of patients in the course of a number of cases of acute renal failure can also be restored. The etiology and prognosis of acute renal failure, general acute nephritis and renal vein thrombosis and poor prognosis, and simple with good prognosis.

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