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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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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
ineective 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 signicant impairment of body functions.
Dispensary observation. Patients are observed for life: with hy-
pertensive form - twice a year, with nephrotic form - four times a year.
Once a year – examination of specialists: gynecologist, dentist, urolo-
gist, otorhinolaryngologist, ophthalmologist. Main activities: rehabili-
tation of foci of infection, physiotherapy, spa treatment, diet. Patients
are under the supervision of a nephrologist, in his absence - a district
therapist or a general practitioner.
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272
Clinical case No. 3
1. What is the preliminary diagnosis?
Preliminary diagnosis: acute nephritic syndrome.
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, hyperbrinogenemia, hypoproteinemia, dysprotein-
emia, hypergammaglobulinemia. Increased creatinine levels. Urine:
low specic 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?
The patient is hospitalized in a specialized hospital, bed rest is
indicated. Patients are prescribed diet therapy, which consists in the
complete exclusion of salt from the diet and the restriction of protein
products, table No. 7. Treatment is carried out individually, depending
on the severity of the disease, the presence of concomitant diseases.
Drug therapy:
With the infectious etiology of the syndrome, antimicrobial agents
are prescribed - “Cephalexin”, “Amoxicillin”, “Azithromycin”.
Immunosuppressive therapy is carried out with the help of cyto-
statics and glucocorticoids – “Prednisolone”, “Methylprednisolone”.
Diuretics reduce the volume of circulating blood – “Diacarb”,
“Veroshpiron”.
Antiplatelet agents and anticoagulants - “Curantil”, “Heparin”.
Calcium channel blockers and ACE inhibitors – “Enalapril”, “Bi-
soprolol” - are used for the treatment of arterial hypertension.
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273
Pre- and probiotics allow to restore the intestinal microora –
“Biform”, “Lactoltrum”, “Enterol”.
Immunostimulators increase the body’s resistance to infection –
“Imunorix”, “Ismigen”.
Multivitamins - “Vitrum”, “Centrum”.
Phytopreparations that support kidney function – “Cystone”,
“Kanefron”.
NSAIDs according to indications - “Ibuprofen”, “Nurofen”, “Di-
clofenac”.
Antihistamines - “Suprastin”, “Cetrin”, “Diazolin”.
Restoration of hemodynamics and improvement of microcircula-
tion - “Actovegin”, “Kavinton”.
Dialysis therapy and plasma exchange are indicated for the rapid
development of renal insuciency.
4. Medical and labor expertise. Dispensary observation.
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
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, signicant neuropsychiatric stress.
Indications for referral to 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, trombocytes; daily loss of protein in urine;
Rehberg test; creatinine, urea, cholesterol, electrolytes, total protein
and fractions; if CKD ABC indicators, bone radiography, alkaline
phosphatase; ultrasound, scintigraphy, radiography and kidney biopsy
according to indications.
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274
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
ineective 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 signicant impairment of body functions.
Dispensary observation. Patients are observed for life: with hy-
pertensive form - twice a year, with nephrotic form - four times a year.
Once a year – examination of specialists: gynecologist, dentist, urolo-
gist, otorhinolaryngologist, ophthalmologist. Main activities: rehabili-
tation of foci of infection, physiotherapy, spa treatment, diet. Patients
are under the supervision of a nephrologist, in his absence - a district
therapist or a general practitioner.
Clinical case No. 4
1. What is the preliminary diagnosis?
Preliminary diagnosis: chemical poisoning. Acute renal failure,
oliguric phase.
2. What additional tests would you recommend to the patient,
and what are the expected results?
1. GBT.
2. GUT.
3. Blood biochemistry (expanded).
4. Coagulogram.
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275
5. acid-base balance.
6. Bacteriological culture urine 3 times.
7. HBsAg, RW, HIV.
8. IFA for markers of viral hepatitis.
9. Blood testing for all types of zoonoses.
10. Coprogram.
11. Bacteriological culture excrement 3 times.
12. CT of the kidneys.
13. Urine analysis according to Zimnitsky.
14. Ultrasound of the abdominal cavity and kidneys.
15. ECG.
16. Chest X-ray.
17. Blood type, Rh aliation.
3. What is the patient’s management?
The goals of treatment are to establish the possible cause of AKI;
withdrawal from an acute condition (elimination of shock, stabiliza-
tion of hemodynamics, restoration of heart rhythm, etc.); restoration of
diuresis; elimination of azotemia, correction of acid-base state; relief
of edema, convulsions; normalization of blood pressure; prevention
of the formation of CKD, transformation of AKI into CKD. Treatment
tactics are divided into conservative (etiological, pathogenetic, symp-
tomatic), surgical (urological, vascular) and active - renal replacement
therapy - dialysis methods (RRT).
Prevention of prerenal AKI includes restoration of CBV, adequate
analgesia (in shock, trauma), correction of acid-base state and water-
electrolyte balance, increase in myocardial contractility.
Therapeutic measures for prerenal AKI depend on changes in he-
modynamic parameters. In case of low CVP and hypotension, it is
necessary to correct hypovolemia by infusion therapy with crystalloid
and colloidal solutions, drugs blood, and against the background of
treatment, the restoration of renal function (a decrease in the level of
urea and plasma creatinine, a sucient rate of diuresis) occurs 24-
36 hours after correction of hemodynamic parameters. In hypotension
with increased CVP, therapy should be aimed at the treatment of heart
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failure: inotropic support (dopamine 5-15 mcg / kg/min, dobutrex
3-15 mcg / kg/min), reduction of afterload (nitroglycerin 5-10 mcg /
kg/min).
The lack of eect from the therapy for 24-36 hours indicates the
development of a renal form of acute renal failure. At an early stage of
the development of renal acute renal failure in the absence of anuria
and hypercatabolism, conservative therapy is carried out, which it is
advisable to start with a mannitol test. 100 ml of a 25% mannitol solu-
tion is administered intravenously by drip. The positive result of the
test is considered if after 1-12.5 hours the diuresis is about 50 ml / h.
In the absence of an eect, the mannitol solution is re-administered
and the rate of diuresis is monitored for two hours. If diuresis does not
increase after the second dose of mannitol (the test is negative), then
this is the basis for performing hemodialysis.
Another method of conservative therapy is treatment with large
doses of furosemide, which is especially eective in toxic acute kid-
ney injury. Against the background of dopamine (1-3 mcg / kg / min)
and antispasmodics (Drotaverine, Euphyllinum), 600-1000 mg of fu-
rosemide is injected intravenously for 15-20 minutes in 100 ml of 5%
glucose solution. The daily dose of furosemide is 2500-3000 mg. The
volume of infusion therapy for oliguria is sharply limited and is calcu-
lated by the formula
Volume of infusion therapy = 500 + diuresis for the previous day
+ the volume of perspiration + visible losses.
The volume of perspiration is 400-500 ml per day. Visible losses –
the volume of losses on drains, with vomiting and stool. When carry-
ing out infusion therapy, it is necessary to take into account the amount
of CVP and the presence of heart failure. With anuria , an infusion of
hypertensive (20 %, 20 %, 40 %) glucose solutions with insulin with-
out electrolytes (potassium, chlorine). Glucose solutions provide the
body with energy and prevent the catabolism of proteins and fats. The
use of anabolic hormones (retabolil) and vitamins (up to 2-26.5 g of
ascorbic acid) helps to reduce the catabolism of proteins and fats. Gas-
tric and intestinal lavage (gastrointestinal-duodenal-intestinal lavage).
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Gastric and intestinal lavage can signicantly reduce the urea content,
with little eect on creatinine levels.
Contraindications to gastric and intestinal lavage are gastrointes-
tinal bleeding and acute intestinal obstruction. With acute renal fail-
ure, which does not respond to conservative treatment, the use of ef-
ferent therapy methods is shown.
Hemodialysis. If it is necessary to carry out RRT for AKI, the
patient is dialyzed from 2 to 6 weeks, until the restoration of kidney
function. When treating patients with AKI who require renal replace-
ment therapy, the following questions should be answered: 1. When
is it better to start the treatment of RRT? 2. What type of RRT should
I use? 3. Which access is better? 4. What level of clearance of soluble
substances should be observed?
The beginning of the RRT. Absolute indications for conducting
RRT sessions with AKI are: 1. Increasing levels of azotemia and im-
paired diuresis according to the recommendations of RIFLE, AKIN,
KDIGO. 2. Clinical manifestations of uremic intoxication: asterixis,
pericardial eusion or encephalopathy. 3. Uncorrectable metabolic
acidosis (pH < 7.1; base deciency -20 or more mmol/l, NSOZ < 10
mmol/l). 4. Hyperkalemia > 6.5 mmol/L and/or pronounced ECG
changes (bradyarrhythmia, rhythm dissociation, severe electrical con-
duction retardation). 5. Hyperhydration (anasarca), resistant to drug
therapy (diuretics).
Relative indications for RRT sessions include a sharp and pro-
gressive increase in the level of urea nitrogen and blood creatinine
without obvious signs of convalescence, when there is a real threat
of the development of clinical manifestations of uremic intoxication.
Indications for “renal support” by RRT methods are: providing
adequate nutrition, removing uid in congestive heart failure, and
maintaining an adequate hydro balance in a patient with multiple or-
gan failure.
According to the duration of therapy, there are the following types
of RRT: intermittent (intermittent) RRT techniques lasting no more
than 8 hours with a break longer than the duration of the next session
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(on average 4 hours); extended RRT methods (RRT) designed to re-
place kidney function for a long time (24 hours or more).
PRRT are conditionally divided into: semi-produced 8-12 hours;
extended 12-24 hours; permanent for more than a day.
Criteria for the selection of PRRT
1. Renal: AKI in patients with severe cardiorespiratory insu-
ciency (AMI, high doses of inotropic support, recurrent interstitial
pulmonary edema, acute pulmonary injury); AKI against the back-
ground of high hyper catabolism (sepsis, pancreatitis, mesenteric
thrombosis, etc.)
2. Extra-renal indications for PRRT: Volume overload, provision
of infusion therapy; Septic shock; ARDS or risk of ARDS; Severe
pancreatitis; Massive rhabdomyolysis, burn disease; Hyperosmolar
comas, preeclampsia of pregnant women.
RRT methods. 1. Hemodialysis is intermittent and prolonged. 2.
Slow low-ow hemodialysis (SLFH) (slow low eective dialysis –
SLED) in the treatment of AKI - the ability to control the hydro bal-
ance of the patient without uctuations in hemodynamics in a shorter
period of time (6-8 hours - 16–24 hours). 3. Prolonged veno-venous
hemoltration (PVVHF). 4. Prolonged veno-venous hemodialtration
(PVVHDF).
Surgical intervention: 1) installation of vascular access; 2) carry-
ing out extracorporeal methods of treatment; 3) elimination of urinary
tract obstruction.
4. Medical and labor expertise. Dispensary observation. The
patient’s disability is established after clarifying the true cause, which
led to the development of AKI. Taking into account the possible de-
velopment of dierent outcomes of AKI, the denition of temporary
or permanent disability also depends.
Dispensary observation. Patients with AKI should be monitored
for 3 months to assess the degree of recovery of kidney function,
a repeat episode of AKI or a worsening of the course of CKD that
occurred before. If a patient has CKD, then his treatment should be
carried out in accordance with the Practical Recommendations of
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279
KDOQI on the management of CKD. If a patient does not have CKD,
it should be borne in mind that such a patient has an increased risk of
developing CKD, and it should be conducted in accordance with the
Practical Recommendations of KDOQI. Patients at risk of developing
AKI should be monitored with careful monitoring of creatinine and
urine volume. Patients are recommended to be divided into groups
according to the degree of risk of AKI. Their management depends
on predisposing factors. First of all, patients should be examined to
identify reversible causes of AKI, which will immediately eliminate
these factors (for example, postrenal).
At the polyclinic stage after discharge from the hospital: com-
pliance with the regime (elimination of hypothermia, stress, physical
overload), diet; completion of treatment (rehabilitation of foci of infec-
tion, antihypertensive therapy) dispensary observation for 5 years (in
the rst year - measurement of blood pressure quarterly, blood, urine,
determination of serum creatinine and calculation of GFR by creati-
nine - Cockcroft -Gault formula). If extrarenal signs persist for more
than 1 month (arterial hypertension, edema), severe urinary syndrome
or their aggravation, a kidney biopsy is necessary, since unfavorable
morphological variants of GN are likely to require immunosuppres-
sive therapy. With persistent anuria, edema, moderate azotemia, trans-
fer to a regional or city-level hospital, with the presence of an articial
kidney device in the clinic (not only simple dialysis machines, but also
devices for extended replacement therapy with the function of hemol-
tration, hemodialtration). Monitoring and RRT regimens in patients
with AKI should be carried out separately from patients with CRF
(CKD, stage 5) who are on programmed dialysis. It is also necessary
to monitor daily hydro balance, uremia indicators, electrolytes, RRT,
as well as the choice of the RRT method - to be carried out individu-
ally, according to the patient’s condition, underlying and concomitant
pathology. Outpatient observation of a nephrologist at the place of
residence, monthly examination of kidney function indicators. Man-
datory permanent card with a note about AKI, duration, number and
type of RRT procedures, GFR level, X-ray contrast studies.
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Clinical case No. 5
1. What is the preliminary diagnosis?
Preliminary diagnosis: secondary amyloidosis, nephrotic stage,
nephrotic syndrome on the background of rheumatoid arthritis.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Immunological examination (immunoglobulins, antinuclear anti-
bodies, RF, CIC, ASL-O, LE-cells); blood tests for markers of viral
hepatitis; determination of the level of glycemia, glucose tolerance
test, glycosylated hemoglobin; lipid prole, calcium and phosphorus
in blood serum; coagulogram; repeated tests for helminthiasis and
protozoa; ultrasound of the abdominal cavity and kidneys, if neces-
sary – others imaging methods; according to indications – excretory
urography, cystography; kidney biopsy with an unclear diagnosis;
consultations with an ophthalmologist, an otolaryngologist, a hema-
tologist and other specialists.
3. What is the patient’s management?
Patients with nephrotic syndrome should seek help from a ne-
phrologist. However, depending on the cause of nephrotic syndrome
the patient may also need specialized consultation. For example, a pa-
tient with lupus nephritis may be prescribed a rheumatologist’s con-
sultation, while diabetic nephropathy will require an endocrinolo-
gist’s consultation. Treatment of nephrotic syndrome depends on the
cause of the disease. Therefore, in addition to the main groups of drugs
prescribed for this syndrome, the patient may also be prescribed etio-
logical treatment (treatment aimed at eliminating the cause of the dis-
ease). With nephrotic syndrome , the following may be prescribed to
the patient:
y glucocorticosteroids;
y cytostatics;
y immunosuppressants;
y diuretics (diuretics);
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