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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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1.73 m2. At each visit – general urine analysis, biochemical blood test
with determination of creatinine content, calculation of glomerular l-
tration rate according to the formula CKD-EPI, uric acid, total choles-
terol, triglycerides, glucose, blood pressure measurement, kidney ul-
trasound (for persons with direct relatives with CKD, for patients with
hematuria). Vaccination against inuenza (in the absence of contrain-
dications in patients with autoimmune kidney diseases) – annually - in
the presence of hypertension, type 2 diabetes, coronary heart disease.
Group 3. GFR ≥ 60 or GFR 45-59 ml/min / 1.73 m2 (CKD with
high risk of TKD and CVC). At least once every 6 months, obser-
vation by a therapist, observation by a nephrologist - at least once
a year. A general urine test when taken under the DN, then as pre-
scribed by a nephrologist, a urine test for albuminuria - at least once
a year (in patients with hypertension and diabetes mellitus), a general
blood test when taken biochemical blood with the determination of
creatinine, uric acid, total cholesterol, triglycerides, glucose, sodium,
then according to the appointment of a nephrologist, calculation of the
glomerular ltration rate according to the formula CKD-EPI at each
examination, ultrasound of the kidneys, then according to the appoint-
ment of a nephrologist, measurement of blood pressure at each visit.
Vaccination against inuenza (in the absence of contraindications in
patients with autoimmune kidney diseases) – annually - in the pres-
ence of hypertension, type 2 diabetes, coronary heart disease. Correc-
tion of therapy (if necessary).
Group 4. GFR 30-59 or GFR 30-44 ml/min/ 1.73 m2 (CKD with
a very high risk of cardiovascular complications). At least once every
3 months, observation by a therapist, observation by a nephrologist -
at least once every 6 months. A general urine test when taken under the
DN, then, according to the appointment of a nephrologist, a urine test
for albuminuria – at least once a year (in patients with hypertension
and diabetes mellitus and PU < 0.5), a general blood test when taken
under the DN, then by appointment of a nephrologist, a biochemi-
cal blood test with determination of creatinine, uric acid, total choles-
terol, triglycerides, glucose, sodium, potassium when taken under the
DN, then by appointment of a nephrologist, calculation of glomerular
t.me/medicina_free
312
ltration rate according to the formula CKD-EPI at each examination,
ultrasound of the kidneys, then by appointment appointment of a ne-
phrologist, measurement of blood pressure at each visit. Vaccination
against inuenza (in the absence of contraindications in patients with
autoimmune kidney diseases) – annually - in the presence of hyperten-
sion, type 2 diabetes, coronary heart disease is carried out.
Group 5. Patients with very high-risk CKD and ESRD with GFR
< 30 ml/min/1.73 m2 are referred to a regional nephrological center
for registration and preparation for renal replacement therapy.
Clinical case No. 9
1. What is the preliminary diagnosis?
Preliminary diagnosis: Acute post-streptococcal glomerulone-
phritis. Exacerbation of chronic tonsillitis, chronic purulent rhinosi-
nusitis.
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?
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
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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 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 signicant 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 eectiveness 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.
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Along with the restriction of sodium chloride, it is necessary to
observe the restriction of liquid. The amount of it during the day, tak-
ing into account liquid dishes, should not exceed 600-800 ml and de-
pends on the volume of daily diuresis and the dynamics of edematous
syndrome. The convergence or reduction of edema is facilitated by
unloading apple or apple-potato days (1-2 times a week). Watermelon,
pumpkin, melon, grapes, bananas have a diuretic eect.
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 NS, 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-
inammatory eects, 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 inammation 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
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315
therapy is required, while taking the drug every other day causes fewer
side eects 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
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 eects. 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 eective, 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 eects of alkylating
cytostatics are bone marrow suppression, the development of infec-
tions and gonad insuciency. 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 eects
and the concentration in the blood serum, which should be checked
regularly. CsA is indicated primarily in patients with minimal changes
and FSGS with frequent recurrence of NS or steroid-resistant NS, with
the development of complications of steroid and cytostatic therapy.
The most serious complications of CsA treatment 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
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signicantly 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 eect of which on the progression of
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, including intra-
clubular coagulation, improve microcirculation, inhibit the synthesis
of antibodies, improve diuresis, reduce blood pressure, slow down
the migration of leukocytes, have an anti-inammatory eect. They
are indicated for nephrotic syndrome, edematous syndrome, increas-
ing CKD, moderate hypertension. Heparin 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
signicant complications of active therapy (hormones, cytostatics,
plasmapheresis) and leading GN syndromes (acute nephritic syn-
drome, NS, AH), working in non-contraindicated types and working
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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
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, platelets; daily loss of protein in urine; Re-
hberg test; creatinine, urea, cholesterol, electrolytes, total protein
and fractions; with CKD, CBS indicators, bone radiography, alkaline
phosphatase; ultrasound, scintigraphy, radiography and kidney biopsy
according 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.
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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. 10
1. What is the preliminary diagnosis?
Preliminary diagnosis: tuberculosis of the kidneys, stage of latent
course
2. What additional tests would you recommend to the patient,
and what are the expected results?
Diagnosis of tuberculosis is carried out in order to recognize the
disease and establish the correct diagnosis, which is based on the study
of the patient’s complaints, the history of the disease and life and the
application of a number of studies.
Laboratory diagnostics (general clinical and biochemical analy-
ses).
Bacteriological diagnostic methods. Detection of Mycobacterium
tuberculosis is a mandatory component in the diagnosis of tuberculo-
sis of the kidneys.
Bacterioscopic examination
Tuberculosis analysis by direct bacterioscopy is the easiest and
fastest way to detect tubercle bacilli in the test material. It is possible
to detect the presence of a Koch wand within 1 hour. When using
this method, the detection of mycobacteria is possible only if they
contain at least 10 thousand microbial bodies in 1 ml of the material.
Therefore, a negative result does not yet serve as a basis for excluding
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the diagnosis of tuberculosis. In addition, the quality of the diagnostic
material aects the eectiveness of the analysis.
Cultural method
The eectiveness of the cultural diagnostic method depends on
the properly collected material for the study. If tuberculosis of the gen-
itourinary system is suspected, urine collected in the morning (after
a night’s sleep) is taken for microbiological examination. The best op-
tion is a collected average portion of morning urine. Sterile dishes are
used to collect the analysis. Before collecting urine, a thorough toilet
of the external genitalia is carried out.
Analysis for tuberculosis by seeding (culture method) is more
sensitive than smear microscopy. MBTs are detected if there are sev-
eral hundred of them in the studied material. The response time is
from 3 weeks to 3 months. Before this period, chemotherapy is pre-
scribed “blindly”.
PCR (polymerase chain reaction) method
Diagnosis of tuberculosis of the kidneys using the PCR technique
is the most promising in modern conditions. The high sensitivity of the
test makes it possible to detect MBT DNA in various biological mate-
rials, which is especially important in the diagnosis of extrapulmonary
forms of the disease. Mycobacteria are detected if there are several
dozen of them in the studied material. This diagnostic method does not
replace the cultural method.
Automated Mycobacterium cultivation system
Diagnosis of kidney tuberculosis using automated mycobacte-
rium cultivation systems MGIT-BACTEC-960 and MB/Bact signi-
cantly reduces the detection time of mycobacterium growth, which
averages 11-19 days.
Sensitivity of diagnostic methods:
PCR - 75 %,
BACTEC — 55,8%,
cultural method — 48.9%,
microscopy — 34%.
Average time of MBT detection by dierent diagnostic methods:
by seeding method - 24 days,
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VASTES — up to 14 days,
PCR — 1 day.
Instrumental diagnostic methods
Ultrasound diagnosis of kidney tuberculosis
Ultrasound diagnostics of kidney tuberculosis helps to determine
the localization of the process, the degree of destruction of organ tis-
sue and to carry out dynamic monitoring. In the presence of cavities
in the kidneys, ultrasound reveals rounded thick-walled formations.
CT (computer) and MRI (magnetic resonance) tomography
These diagnostic methods make it possible to identify the degree
of organ damage, the exact localization of the pathological process
and the presence of specic changes in regional lymph nodes.
Angiography
It helps to study the functional state of blood vessels and the prev-
alence of the lesion site.
3. What is the patient’s management?
Treatment of kidney tuberculosis is a long process. It requires
a lot of patience and self-discipline from the patient. In tuberculosis,
not only the aected organ suers, but also the entire body as a whole.
The strategy of the treatment process is to suppress the mycobac-
terium population as quickly as possible and to regress pathological
changes caused by infection.
Treatment of kidney tuberculosis should be comprehensive, tak-
ing into account the patient’s age and concomitant pathology:
impact on infection;
the eect on the sick organism as a whole (immune status) and
on the pathological processes occurring in it (pathogenetic treatment);
reduction of the level and elimination of manifestations of symp-
toms of the disease;
local treatment,
the use of surgical methods of treatment.
First-line drugs are highly eective and low-toxic. They are the
main ones in the treatment of tuberculosis. These include:
rifampicin, isoniazid, metazid, ftivazid, phenazid,
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