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one of the most important elements of the complex therapy of CGN.

The diet No. 7 according to M.I. Pevsner with variation 7a, 7b is used.

Diet therapy is designed for a long time, therefore, when prescrib-

ing it, it is necessary to take into account the clinical form of the dis-

ease, its course (remission or exacerbation), stage (compensated or

with CKD phenomena). In patients with latent and hematuric forms

(with isolated urinary syndrome), dietary restrictions should be mini-

mal. Nutrition should correspond to the physiological needs of the

body with an average protein content of 1 g per 1 kg of body weight in

the daily diet with a slight restriction of table salt (up to 6-8 g per day)

and without signicant uid restriction. The diet should include veg-

etable products rich in vitamins C, P (lemon, rosehip infusion, black

currant, etc.), strengthening the vascular wall and reducing its perme-

ability. In patients with hypertensive CGN with the same protein con-

tent, a stricter restriction of table salt and liquid is required in the daily

diet. With all clinical forms of CGN, especially with hypertension,

a dairy-vegetable diet is preferred. In the case of persistent and per-

sistent hypertension, it is recommended to periodically spend fasting

days (fruit-rice, potato, vegetable, etc.). Such a diet, poor in sodium

chloride and rich in potassium, helps to reduce blood pressure and

increases the eectiveness of antihypertensive agents. With nephrotic

and mixed forms of CGN, a very strict and long-term restriction of

table salt (3-4 g per day, taking into account its content in food) and

liquid is required. It should be borne in mind that bread is rich in salt

(in white bread – 0.6%, in black – 0.75% sodium chloride) and butter.

For such patients, a special “kidney bread” is baked, that is, without

adding salt, and the oil is repeatedly washed or soaked in water. With

persistent and persistent edema, it is recommended to carry out so-

called “zigzags”, that is, periodically, then increase (with a decrease in

edema), then again strictly limit the amount of salt in the diet.

Along with the restriction of sodium chloride, it is necessary

to observe the restriction of liquid. The amount of it during the day,

taking into account liquid dishes, should not exceed 600-800 ml and

depends on the volume of daily diuresis and the dynamics of edema-

tous syndrome. Convergence or unloading apple or apple-potato days

t.me/medicina_free

262

(1-2 times a week) contribute to the reduction of edema. Watermelon,

pumpkin, melon, grapes, bananas have a diuretic eect.

Pathogenetic treatment of glomerulonephritis. Immunosuppres-

sive therapy is used to suppress the activity: GC, non-selective and

selective cytostatics and cyclosporine-A (CSA). When prescribing

immunosuppressive therapy, the following provisions should be fol-

lowed:

1. Immunosuppressive therapy is always indicated for high activ-

ity of GN.

2. First-time nephrotic syndrome, especially without hematuria

and hypertension, is always an indication for the treatment of GC.

3. With rapidly progressing forms of nephritis (with a rapid in-

crease in creatinine levels), it is mandatory to prescribe immunosup-

pressants - large doses of GC and cytostatics inside and / or in the form

of “pulses”.

Glucocorticoids (GC), which have immunosuppressive and anti-

inammatory eects, have remained the main means of pathogenetic

therapy of nephritis for several decades. More often used orally – pred-

nisone in high (1-2 mg / kg per day) or moderately high (0.6–0.8 mg /

kg per day) doses, daily in 2-3 doses or once in the morning, for a long

time (1-4 months), followed by a slow decrease. An alternating mode

is also possible, when the patient takes a double daily dose every other

day in the morning.

With high activity of renal inammation to quickly achieve very

high concentrations of GC in blood plasma, “pulse therapy” is indi-

cated – intravenous administration of ultra-high doses (0.8–1.2 g) of

methylprednisolone or prednisolone for three days in / in drip.

Maintenance therapy of GC is carried out for two months at a dose

of 10-20 mg / day. The timing of maintenance therapy is determined

empirically, usually two months. With systemic diseases, longer ther-

apy is required, while taking the drug every other day causes fewer

side eects than daily therapy. In such situations, the dose of GC for

alternating therapy is 2-3 times higher than with daily intake. In this

regard, the best tactic of maintenance therapy of GC is considered to

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263

reduce the daily dose to the lowest level, and then switch to an alter-

nating mode using a two-time dose of daily intake.

Cytostatic drugs in the treatment of nephritis are used somewhat

less frequently because of the greater severity of side eects. As a rule,

alkylating compounds are used – cyclophosphamide (at a dose of 1.5-

2 mg / kg per day) and chlorbutin (at a dose of 0.1-0.2 mg / kg per

day); antimetabolite azathioprine is less eective, although less toxic.

The decrease in the number of white blood cells occurs within a few

days or weeks. During this period, it is important to check the num-

ber of leukocytes in the peripheral blood every 2-3 days so that when

they decrease to the lower permissible level, the dose of the drug can

be reduced or canceled. The most serious side eects of alkylating

cytostatics are bone marrow suppression, the development of infec-

tions and gonad insuciency. Other complications: hepatitis, alope-

cia, hemorrhagic cystitis, gastrointestinal disorders and an increased

risk of developing tumors. The initial dose of CsA for adults in a ne-

phrological clinic is 3-5 mg / kg, for children - 6 mg / kg per day. In the

future, the dose depends on the tolerability, the presence of side eects

and the concentration in the blood serum, which should be regularly

check. CsA is indicated primarily in patients with minimal changes

and gastroscopy with frequent recurrence of nephrotic syndrome or

steroid-resistant NS, with the development of complications of steroid

and cytostatic therapy. The most serious complications of CsA treat-

ment are hypertension and nephrotoxicity.

Mycophenolate mofetil, a derivative of mycophenolic acid, is an

inosine monophosphate dehydrogenase inhibitor that depletes the re-

serves of guanidine nucleotides in cells, selectively inhibits the prolif-

eration of T and B lymphocytes, the production of AT and the forma-

tion of cytotoxic T lymphocytes.

Not only immunosuppressive therapy, but also the so-called non-

immune nephroprotective therapy, the possibilities of which have sig-

nicantly expanded over the past decade, can stabilize the course of

GN, slow down its progression, and sometimes even lead to its reverse

development. At the present stage, we can talk about four methods of

nephroprotective therapy, the eect of which on the progression of

t.me/medicina_free

264

GN has been proven. These are: ACE inhibitors and angiotensin II

receptor blockers; heparin; dipyridamole; lipid-lowering drugs, pri-

marily statins.

Anticoagulants reduce intravascular coagulation, improve micro-

circulation, inhibit the synthesis of antibodies, improve diuresis, re-

duce blood pressure, slow down the migration of leukocytes, have an

anti-inammatory eect. They are indicated for nephrotic syndrome,

edematous syndrome, increasing CKD, moderate hypertension. Hepa-

rin 5000-10000 units 4 times a day subcutaneously into the anterior

abdominal wall. The course is 6-8 weeks with gradual cancellation.

Weekly monitoring of APTT is required.

4. Medical and labor expertise. Dispensary observation. Indi-

cations for hemodialysis: a decrease in glomerular ltration of 15 - 10

ml / min, it is important not to miss the deadline for entering the pa-

tient into hemodialysis with CKD. Examination of working capacity.

The duration of temporary disability depends on the clinical form of

the disease and the state of kidney function, which occurs with an ex-

acerbation of the disease: exacerbation of the latent form - the duration

of temporary disability – 14-20 days; mild urinary syndrome - 20-25

days; hypertensive form of glomerulonephritis - 25-30 days; nephrotic

form - 40-45 days. With an unfavorable course of the disease, signs of

CKD, patients are referred to the MSEC to establish a disability group.

Patients with CGN in remission are able to work, with rare re-

lapses, having isolated changes in urine, NS without exacerbation,

medically controlled hypertension of I-II degree, in the absence of

signicant complications of active therapy (hormones, cytostatics,

plasmapheresis) and leading GN syndromes (acute nephritic syn-

drome, NS, AH), working in non-contraindicated types and working

conditions. The ability to work persists at the pre-azotemic and initial

stages of CKD.

Contraindicated types and working conditions: 1) absolute: hard

physical labor; work at a rigidly set pace (on the conveyor), in a static

pose, unfavorable production conditions (low or high temperatures,

high humidity, dust, smoke, drafts, etc.), in contact with nephrotic

t.me/medicina_free

265

poisons; work related to the impact on the body of vibration, high fre-

quency currents; irregular working day, night shifts; 2) relative: mod-

erate physical labor, work associated with prolonged standing, forced

body position, signicant neuropsychiatric stress.

Indications for referral in the medical and social expertise. AGN

with chronic disease, CGN with continuous recurrence, current NS,

progressive or high grade III hypertension, extrarenal complications

of the disease or treatment, newly diagnosed or progressive termi-

nal CKD.

The required minimum of examination: urine tests (repeated);

clinical blood analysis, platelets; daily loss of protein in urine; Reh-

berg test; creatinine, urea, cholesterol, electrolytes, total protein and

fractions; if CKD ABC indicators, bone radiography, alkaline phos-

phatase; ultrasound, scintigraphy, radiography and kidney biopsy ac-

cording to indications.

Criteria for disability in adult glomerulonephritis

Disability is not established if the patient has:

Stage 1 CKD, GFR more than 90 ml/min/1.73 m2;

Stage 2 CKD, GFR within 89-60 ml/min/1.73 m2;

Stage 3A CKD, GFR 59-45 ml/min/1.73 m2.

Group III disability is established if the patient has: Stage 3 CKD,

GFR 44-30 ml/min/1.73 m2. Nephrotic / nephritic syndromes with

ineective treatment with moderate impairment of body functions.

Disability of group II is established if the patient has: Stage

4 CKD, GFR 29-15 ml/min/ 1.73 m2, preparation for dialysis. Stage

5 CKD (GFR below 15 ml/min/1.73 m2) in the absence of dialy-

sis complications.

Disability of group I is established if the patient has: Stage 5 CKD,

GFR below 15 ml/min / 1.73 m2, in the presence of complications

with signicant impairment of body functions.

Dispensary observation. Patients are observed for life: with

hypertensive form - twice a year, with nephrotic form - four times

a year. Once a year – examination of specialists: gynecologist, dentist,

urologist, otorhinolaryngologists, ophthalmologist. Main activities:

rehabilitation of foci of infection, physiotherapy, spa treatment, diet.

t.me/medicina_free

266

Patients are under the supervision of a nephrologist, in his absence -

a district therapist or a general practitioner.

Clinical case No. 2

1. What is the preliminary diagnosis?

Preliminary diagnosis: chronic mesangial proliferative glomeru-

lonephritis, hematuric form.

2. What additional tests would you recommend to the patient,

and what are the expected results?

Laboratory and instrumental studies. Blood: leukocytosis, in-

creased ESR, hyperbrinogenemia, hypoproteinemia, dysprotein-

emia, hypergammaglobulinemia. Increased creatinine levels. Urine:

low specic gravity, proteinuria, leukocyturia, hematuria, cylin-

druria. Rehberg-Tareev test: reduction of glomerular ltration and

tubular reabsorption. Nechiporenko’s test: hematuria, cylindruria.

Zimnitsky’s test: hypostenuria, isostenuria, nocturia. Radioisotope

renography is a symmetrical decrease in ltration and excretory func-

tions of the kidneys. Excretory urography is a symmetrical decrease

in the ltration function of the kidneys. Kidney biopsy: morphological

variants of kidney damage.

3. What is the patient’s management?

Treatment is carried out over a long period and can take from

several months to several years, and sometimes throughout the pa-

tient’s life. Treatment tasks: 1) achieve the reverse development

of kidney lesions with the restoration of their function; 2) stop the

progression of nephritis; 3) slow down the rate of increase in CKD.

Mode: avoid hypothermia, excessive physical exertion, psychoemo-

tional stress. It is forbidden to work at night, in hot and cold rooms,

business trips, overheating, sunburn are not recommended. Diet: is

one of the most important elements of the complex therapy of CGN.

The diet No. 7 according to M.I. Pevsner is used with variation 7a, 7b.

t.me/medicina_free

267