Don’t Be Careless When Diagnosing Renal Insufficiency, These 3 Questions Need To Be Clarified!

The patient is a middle-aged man. After catching a cold more than one month ago, he developed symptoms of coughing and sputum (a small amount of white sticky sputum). He also felt chest tightness, tiredness, and shortness of breath after walking and activities, but he ignored it.

The patient's symptoms worsened more than 10 days ago, and then he developed edema of both lower limbs, paroxysmal dyspnea at night, and no fever and other symptoms.

Click to Cistanche for kidney disease

The day before admission, the patient developed vomiting after eating, accompanied by abdominal distension and pain, and was extremely depressed. He underwent chest CT and abdominal color ultrasound examinations at the outpatient department of our hospital and was hospitalized for "pulmonary infection".

History:

He has a history of hypertension for 5 years and currently takes 1 nifedipine controlled-release tablet daily to reduce blood pressure. He reports that his blood pressure is under control.

The patient had a history of diabetes for 2+ years, and his blood sugar had been as high as 20mmol/L. He had not taken any anti-diabetic drugs recently and reported that his blood sugar was stable. He was diagnosed with diabetic retinopathy in an outside hospital half a year ago and underwent surgery.

Renal insufficiency was found, but the patient was not treated; he denied a history of infectious diseases such as hepatitis and tuberculosis, and had no history of drugs, allergies, or genetics.

Specialist examination: The patient's energy, eating, and sleep were poor. The amount of urine had been significantly reduced recently, the stool was thin, and there was no significant increase or decrease in weight. Dullness was detected on percussion in both the middle and lower lungs, breath sounds were weakened, and a small number of moist rales were heard in both lungs. The heart boundary was enlarged, the heart sounds were powerful and rhythmic, no pathological murmurs were heard in each valve area, the abdomen was soft, there was no obvious tenderness and rebound tenderness, and there was moderate pitting edema in both lower limbs.

Auxiliary inspection:

Chest CT

1. Small to moderate pleural effusion on the right side of the pleural cavity, accompanied by incomplete expansion of part of the lung tissue in the right lower lung; a small amount of pleural effusion on the left side.

2. There are scattered spots, patches, and cord shadows in the remaining lungs, which is considered to be a little inflammation. It is recommended to review after treatment.

3. The left atrium and ventricle are enlarged; the density of some cardiac chambers is reduced, indicating the possibility of anemia; the main pulmonary artery is thickened, with a diameter of about 3.4cm, indicating pulmonary hypertension.

4. Bone hyperplasia and degeneration of some thoracic vertebrae.

Abdominal color ultrasound

Polypoid lesions of the gallbladder; cyst in the left kidney; bilateral pleural effusion. The electrocardiogram showed sinus tachycardia and STT changes.

Preliminary diagnosis: 1. Community-acquired pneumonia, not severe; 2. Chronic heart failure; 3. Type 2 diabetes; 4. Hypertension (grade 3 very high risk); 5. Chronic renal insufficiency.

After admission, blood sugar and blood pressure were monitored, oxygen inhalation, ampicillin sodium intravenous anti-infection, and furosemide intravenous diuretic treatment were given. Ambroxol oral liquid was given to relieve cough and expectoration, and spironolactone tablets 40 mg bid each time were given for potassium-sparing diuretic treatment. Oral nifedipine controlled-release tablets were used to control blood pressure and other symptomatic treatments.

▎Complete auxiliary examinations after admission:

Routine blood test: absolute neutrophil count 7.41×109/L, neutrophil percentage 86.20%, hemoglobin 88 g/L, C-reactive protein normal, and erythrocyte sedimentation rate 40.0 mm/h.

Blood lipids: low-density lipoprotein 3.12 mmol/L, normal blood sugar, and normal fructosamine.

Renal function: urea 28.34 mmol/L, creatinine 803.30 μmol/L, β2 microglobulin 11.47 mg/L, cystatin C 4.90 mg/L.

17 items of liver function + myocardial enzyme spectrum: total protein 52.3 g/L, albumin 31.5 g/L, lactate dehydrogenase 303.0 U/L, α-hydroxybutyrate dehydrogenase 236.0 U/L, creatine kinase 833.0 U /L, creatine kinase isoenzyme 42.0 U/L.

Mycoplasma pneumonia test: negative (-).

Electrolytes: potassium 5.60 mmol/L, sodium 149.30 mmol/L, chlorine 116.10 mmol/L, calcium 1.86 mmol/L.

Urine routine: occult blood 1+, urine glucose 2+, urine protein 2+, urine specific gravity 1.020.

Color Doppler ultrasound of urinary system: left renal septal cyst; prostate calcification.

Color Doppler Ultrasound of both kidneys: The shape and size of both kidneys were normal, and the capsule was smooth. A 1.2cmx1.0cm cystic dark area with a regular shape and clear boundaries was found in the parenchyma of the left kidney. The echo of the parenchyma of the right kidney was uniform and no definite abnormal echo was found in the collecting system of both kidneys.

Cardiac color ultrasound: left atrium enlargement; pulmonary artery widening; mild mitral and tricuspid valve regurgitation; aortic valve degeneration; left ventricular systolic function measurement decreased.

Based on the patient's medical history, question 1: What is the patient's diagnosis? Is it chronic renal failure? Or is it an acute exacerbation of chronic renal insufficiency?

The patient was a middle-aged male. His urine output had decreased significantly in the past six months, about 300 ml/d, and his kidney function showed abnormality. Color ultrasound of the urinary system showed that the size of both kidneys was normal (shrinking of the kidneys usually indicates chronic disease, but even diabetic nephropathy and polycystic kidney disease Chronic (can also manifest as normal kidney size), accompanied by electrolyte imbalance (hyperkalemia, hyperchloremia, and hypocalcemia), anemia, and is considered to be chronic renal insufficiency.

So, are there factors for acute exacerbation? The patient had no renal hypoperfusion before admission, and his blood pressure and peripheral circulation were normal on admission. Considering the possibility of no acute exacerbation, the glomerular filtration rate was calculated based on the patient's age of 56 years and creatinine level of 6.1ml/min/1.73m2. Chronic renal failure (CKD stage 5) was considered and hemodialysis was indicated.

Question 2: What is the patient's primary disease?

Diabetic retinopathy and diabetic nephropathy often occur together, which means that the patient is more likely to have diabetic nephropathy. However, the patient currently stopped taking anti-diabetic drugs, and the glycated hemoglobin and fructosamine were normal when he was admitted to the hospital, indicating that his blood sugar condition in the past three months was acceptable.

However, because the medical history is inconsistent, we need to consider: Whether is it combined with renal insufficiency caused by other diseases. Are there combined factors of acute exacerbation? Diabetic nephropathy is mostly diagnosed clinically. Due to chronic renal insufficiency, the kidney tissue becomes fibrotic and fragility-increasing, and the risk of renal biopsy is greater. Pathologically, glomerular hypertrophy and mild thickening of the glomerular basement membrane can be seen in the early stages. , the mesangial area widens, and in the later stage, typical K-W nodules may be formed, or diffuse glomerulosclerosis may be present; the possibility of diabetic nephropathy in this patient is high, and the gold standard is needle biopsy, but this patient Don't even think about doing this.

Question 3: What should be the next step in treatment?

The patient was admitted to the hospital with underlying diseases such as diabetes and hypertension. We will explain this case of chronic heart failure, community-acquired pneumonia, and renal insufficiency one by one.

1. Hypertension (level 3 very high-risk group): The patient has a longer history of hypertension than a history of renal insufficiency. Secondary hypertension (renal vascular stenosis, pheochromocytoma, etc.) is excluded and primary hypertension is considered. The patient currently has electrolyte imbalance (hyperkalemia) and renal insufficiency, so it is not appropriate to use ACEI/ARB and potassium-sparing diuretics. Common beta-receptor antagonists have cardioprotective functions in chronic heart failure, but they can mask the symptoms of diabetes. Symptoms of hypoglycemia are rarely used in this type of patient. In this case, CCB and potassium-depleting diuretics can be used first according to the patient's blood pressure level.

2. Diabetes: The increase in blood sugar and urinary protein play an important role in the progression of kidney function. Controlling blood sugar is the key. Monitor fasting and post-meal blood sugar levels to understand the characteristics of blood sugar fluctuations and rationally select related drugs. The following are hypoglycemic measures Summary of Drugs.

3. Community-acquired pneumonia: The patient is a middle-aged male. The common causative bacteria of community-acquired pneumonia are mostly Streptococcus pneumoniae. The semi-synthetic penicillins (strongly effective against Gram-positive bacteria) are used for admission, but attention needs to be paid. What is more, penicillins can induce interstitial nephritis, manifested as small molecule urine and low specific gravity urine, etc., and can also form crystals in the urine. When the number of crystals increases, damage to the renal tubular epithelial cells may occur.

4. Kidney: Actively treat basic diseases such as hypertension and diabetes, and provide nutritional support. Currently, this patient has indications for dialysis. Hemodialysis is recommended. If there are factors of acute exacerbation, renal function can be restored compared to before, and then based on the patient's comprehensive assessment the need for long-term maintenance hemodialysis treatment.

Assessing complications related to kidney disease

1. Combined electrolyte imbalance:

①Hyperkalemia: Avoid a high-potassium diet, and temporarily switch to potassium-lowering treatment such as sodium bicarbonate, high sugar + insulin, calcium, diuretics, etc. If it cannot return to normal, hemodialysis is possible;

② Hypernatremia and hyperchloremia: Change most current solutions to sugar water + insulin to reduce the input of sodium chloride;

③Hypocalcemia: Hypocalcemia, hyperphosphatemia, and elevated parathyroid hormone often indicate chronic renal insufficiency. After improving inorganic phosphorus and parathyroid glands, drugs should be selected rationally.

2. Renal anemia (moderate anemia): First, give a subcutaneous injection of erythropoietin 10,000iu qw to correct anemia, and continue to check ferritin and transferrin saturation to evaluate whether there are indications for iron transfusion and oral iron supplements.

3. Combined with chronic heart failure: The treatment principles of heart failure include reducing water and sodium retention, cardiotonic drugs, and reducing the heart's work; when combined with renal failure, diuretic mixtures can be used to reduce the load, which is beneficial to both heart failure and renal failure.

Diagnosis and treatment ideas for patients with renal insufficiency from the first diagnosis

1. Determine whether renal insufficiency is acute, chronic o,r chronic + acute.

2. If a chronic disease is considered to determine the primary disease, whether a renal biopsy is required.

3. Determine whether there are complications.

How Does Cistanche Treat Kidney Disease?

Cistanche is a traditional Chinese herbal medicine used for centuries to treat various health conditions, including kidney disease. It is derived from the dried stems of Cistanche deserticola, a plant native to the deserts of China and Mongolia. The main active components of cistanche are phenylethanoid glycosides, echinacoside, and acteoside, which have been found to have beneficial effects on kidney health.

Kidney disease, also known as renal disease, refers to a condition in which the kidneys are not functioning properly. This can result in a buildup of waste products and toxins in the body, leading to various symptoms and complications. Cistanche may help treat kidney disease ase through several mechanisms.

Firstly, cistanche has been found to have diuretic properties, meaning it can increase urine production and help eliminate waste products from the body. This can help relieve the burden on the kidneys and prevent the buildup of toxins. By promoting diuresis, cistanche may also help Reduce high blood pressure, a common complication of kidney disease.

Moreover, cistanche has been shown to have antioxidant effects. Oxidative stress, caused by an imbalance between the production of free radicals and the body's antioxidant defenses, plays a key role in the progression of kidney disease. ies help neutralize free radicals and reduce Oxidative stress, thereby protecting the kidneys from damage. The phenylethanoid glycosides found in cistanche have been particularly effective in scavenging free radicals and inhibiting lipid peroxidation.

Additionally, cistanche has been found to have anti-inflammatory effects. Inflammation is another key factor in the development and progression of kidney disease. Cistanche's anti-inflammatory properties help reduce the production of pro-inflammatory cytokines and inhibit the activation of inflammation mandatory pathways, thus alleviating inflammation in the kidneys.

Furthermore, cistanche has been shown to have immunomodulatory effects. In kidney disease, the immune system can be dysregulated, leading to excessive inflammation and tissue damage. Cistanche helps regulate the immune response by modulating the production and activity of immune cells, such as T cells and macrophages. This immune regulation helps reduce inflammation and prevent further damage to the kidneys.

Moreover, cistanche has been found to improve renal function by promoting the regeneration of renal tubes with cells. Renal tubular epithelial cells play a crucial role in the filtration and reabsorption of waste products and electrolytes. In kidney disease, these cells can be damaged, leading to damaged renal function. Cistanche's ability to promote the regeneration of these cells helps restore proper renal function and improve overall kidney health.

In addition to these direct effects on the kidneys, cistanche has been found to have beneficial effects on other organs and systems in the body. This holistic approach to health is particularly important in kidney disease, as the condition often affects multiple organs and systems. che has been shown to have protective effects on the liver, heart, and blood vessels, which are commonly affected by kidney disease. By promoting the health of these organs, cistanche helps improve overall kidney function and prevent further complications.

In conclusion, cistanche is a traditional Chinese herbal medicine used for centuries to treat kidney disease. Its active components have diuretic, antioxidant, anti-inflammatory, immunomodulatory, and regenerative effects, which help improve renal function and protect the kidneys from further damage. , cistanche has beneficial effects on other organs and systems, making it a holistic approach to treating kidney disease.