How Should This Patient With Nephrotic Syndrome Be Treated If He Is Unwilling To Undergo Puncture And Does Not Take Hormones?

A patient who was diagnosed with nephrotic syndrome asked me, "Doctor, I have taken medicine, why is my edema still not gone?" Faced with this problem raised by the patient, I sighed. This matter makes sense. long......

The patient was 66 years old. He developed edema of both lower limbs 7 months ago. After examination at a nearby hospital, he was found to have massive proteinuria and hypoalbuminemia. He was diagnosed with nephrotic syndrome. The hospital gave the patient tripterygium wilfordii and sartan antihypertensive drugs. After treatment, the patient's edema waxed and waned, and his urinary protein quantification remained at about 6g/d. Recently, he was admitted to our hospital because of worsening edema.

Click to Cistanche for kidney disease

The patient had high blood pressure for many years, had a cardiac stent removed, and had been treated with sartan antihypertensive drugs, lipid-lowering drugs, and anticoagulants. He had no history of diabetes.

After hospitalization, the patient's urine protein quantification was found to be 11.35g/d, plasma albumin was 22.4g/L, and the anti-phospholipase A2 receptor antibody was positive. Diabetic nephropathy and other kidney diseases were ruled out, and he was diagnosed with nephrotic syndrome and primary membranous nephropathy.

Nephrotic syndrome is a common manifestation of multiple kidney diseases

There is no protein in normal human urine, urine protein is negative, and urine protein quantification is <0.15g/d. Proteinuria occurs after kidney damage, and the more severe the damage, the more protein in the urine.

If the urine protein quantification is ≥3.5g/d, it is massive proteinuria. Massive proteinuria causes a large amount of protein in the blood to be lost from the urine, which will cause hypoalbuminemia. Hypoalbuminemia (plasma albuminemia) caused by massive proteinuria Protein <30g/L) is called nephrotic syndrome.

There are many causes of kidney damage, such as primary kidney disease, diabetic nephropathy, purpura nephritis, lupus nephritis, systemic small vessel vasculitis, etc., but no matter what the cause, as long as these two conditions are met: urine protein quantification ≥ 3.5 g/d and plasma albumin <30g/L, nephrotic syndrome is diagnosed.

Therefore, nephrotic syndrome is not a disease, but a common manifestation of many kidney diseases. Although they are all nephrotic syndromes, the treatment measures and disease outcomes are different for different causes of kidney disease. For example, primary nephrotic syndrome requires hormone therapy, while the use of hormones is prohibited for diabetic nephropathy. Therefore, in order to accurately treat nephrotic syndrome, the cause must be investigated, including detailed medical history, blood drawing, and various tests. Among them, renal biopsy pathology examination, that is, renal puncture, is the most definite diagnostic method.

Can antiphospholipase A2 receptor antibody testing replace renal puncture?

Through medical history and fundus examination, the possibility of diabetic nephropathy was ruled out; through various tests, secondary kidney diseases such as lupus nephritis and antineutrophil cytoplasmic antibody (ANCA)-related small vessel vasculitis were ruled out. After examination, it was found that the patient's anti-phospholipase A2 receptor antibody test was positive.

Anti-phospholipase A2 receptor antibody is a glycoprotein on the glomerular podocyte membrane. It is divided into M type and N type. It has been confirmed that M type is the main target antigen of autoantibodies. Antiphospholipase A2 receptor antibody is a specific marker for primary membranous nephropathy. Its diagnostic value for primary membranous nephropathy can even replace renal pathology. A negative test cannot exclude primary membranous nephropathy, but a positive test is basically It is primary membranous nephropathy. In addition, changes in its content can also be used as the main criterion for determining the severity of the disease and its efficacy.

If the patient's indicator is positive, renal puncture is not needed and the patient can be diagnosed with primary membranous nephropathy.

Many patients are unwilling to undergo renal puncture. In fact, the thoughts of these patients are understandable. However, some kidney diseases cannot be concluded by blood tests alone, and only renal puncture can be diagnosed, so this is a difficult problem faced by clinical patients.

Primary membranous nephropathy must be treated aggressively when discovered!

Filtration function is one of the main functions of the kidney, in which the glomerular filtration membrane plays a filtration role. The glomerular filtration membrane is divided into three layers, and the middle layer is called the glomerular basement membrane. Membranous nephropathy, in layman's terms, is a diffuse lesion of the glomerular basement membrane. The result of the lesion is damage to the filtration membrane, and a large amount of protein in the blood leaks from the kidneys, forming a large amount of proteinuria, and leading to hypoalbuminemia and Severe edema.

According to the cause, membranous nephropathy is divided into primary membranous nephropathy, which is a disease of the kidney itself; and secondary membranous nephropathy, which is kidney disease caused by other diseases, such as systemic lupus erythematosus, hepatitis B virus infection, systemic Small vessel vasculitis, malignant tumors, etc.

This patient has primary membranous nephropathy. The exact cause of primary membranous nephropathy is currently unknown, but it may be related to environmental pollution such as smog.

Membranous nephropathy is not only a problem of low protein and edema. Severe membranous nephropathy can cause serious complications, such as infection, thromboembolic diseases (such as pulmonary embolism, renal vein thrombosis, etc.), acute renal failure, etc. Therefore, if nephrotic syndrome is discovered, it must be treated aggressively.

How to treat primary membranous nephropathy symptomatically?

The most obvious symptom of this patient is edema, so let's first talk about how to treat edema.

Edema in kidney disease is divided into two categories: nephritic edema and nephrotic edema. The former is caused by sodium and water retention and is seen in glomerulonephritis. The edema mainly occurs in parts with loose tissue, such as eyelids, face, etc., and is often accompanied by high blood pressure; The latter is caused by low protein and is seen in nephrotic syndrome. Edema mainly occurs in low-lying parts such as the lower limbs, and is often accompanied by pleural effusion, ascites, etc. Of course, severe kidney disease can present with both.

The patient's edema was nephrotic edema. Generally speaking, edema will occur when plasma albumin is less than 30g/L. The lower the albumin, the more serious the edema will be. In this case, it is not advisable to simply infuse albumin, because the infused albumin will also be lost in the urine, which will not only be useless and expensive but will also aggravate the condition. The most effective treatment for nephrotic edema is to "fix leaks" to avoid protein loss.

Since autoimmune damage is involved in the pathogenesis of primary membranous nephropathy, the most effective measure for the treatment of primary membranous nephropathy is to suppress immunity. According to the guidelines, primary membranous nephropathy should be treated with hormones combined with immunosuppressants. The combination of the two can suppress autoimmune damage, repair the glomerular basement membrane, and plug "leaks".

However, the elderly refuse to take these medicines due to concerns about the side effects.

Difficulties in treating nephrotic syndrome, only doctors know

As mentioned earlier, patients are unwilling to undergo renal puncture, which is the first obstacle in the clinical treatment of nephrotic syndrome.

The second obstacle is medication.

The patient has been receiving treatment since the edema was discovered. I had been treated with various measures for 7 months, but instead of getting better, my condition gradually worsened, indicating that the treatment measures needed to be adjusted.

What should I do if the patient rejects the treatment plan recommended by the guideline and wants the horse to run but not let it eat grass?

Doctors never deny the side effects of hormones: infection, central obesity, elevated blood sugar, gastric and duodenal ulcers caused by excessive gastric acid secretion, insomnia, calcium loss, etc. But which drug can replace the efficacy of hormones?

Not only are patients afraid of the side effects of hormones, but doctors are also very cautious about using hormones for patients. Not only are they worried that patients will get infected, but they also need to take measures to prevent side effects, such as calcium supplementation, use of gastric mucosal protective agents, monitoring and controlling blood sugar, etc. At the same time, it is necessary to record the medication time and guide patients to reduce the dosage regularly. Doctors also hope to have a drug with surprising efficacy and few side effects to relieve patients' pain.

We have increased the dosage of sartan antihypertensive drugs for the patient, combined with gliflozin antihyperglycemic drugs to reduce urinary protein and delay renal damage, and also used statin lipid-lowering drugs. Apart from that, I can't think of a better way to continue to do ideological work for the patient.

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.