How to treat nephrotic syndrome

summary

Nephrotic syndrome can be caused by a variety of causes, with increased glomerular basement membrane permeability, manifested as a group of clinical symptoms of massive proteinuria, hypoproteinemia, high edema, hyperlipidemia. Now let me share some of my experiences.

How to treat nephrotic syndrome

Method 1: Patients with severe edema and hypoproteinemia need to rest in bed. After the edema disappeared and the general condition improved, you can get up and exercise. The normal amount of high quality protein (mainly animal protein rich in essential amino acids) was 0.8-1.0 g / (kg · d). The amount of heat should be sufficient, and the daily weight per kilogram should not be less than 30-35kcal. Although patients lose a lot of urine protein, but because high protein diet increases glomerular hyperfiltration, can aggravate proteinuria and promote the progress of renal disease, so it is generally no longer advocated. Low salt (< 3G / D) diet should be used when edema occurs. In order to reduce hyperlipidemia, the diet rich in saturated fatty acids (animal fat) should be reduced, and the diet rich in polyunsaturated fatty acids (such as vegetable oil, fish oil) and soluble fiber (such as beans) should be increased.

Methods 2: 1. Diuresis and detumescence (1) thiazide diuretics mainly act on the thick wall segment of ascending branch of medullary loop and the anterior segment of distal convoluted tubule, and increase the excretion of potassium by inhibiting the reabsorption of sodium and chlorine. Long term use should prevent hypokalemia and hyponatremia. * * (2) potassium retention diuretics mainly affect the posterior segment of distal convoluted tubules, sodium excretion and chlorine excretion, but potassium retention is suitable for patients with hypokalemia. When used alone, diuretic effect is not significant, it can be combined with thiazide diuretics. Spironolactone, an aldosterone antagonist, is commonly used. Long term use should prevent hyperkalemia, and patients with renal insufficiency should be cautious. (3) Loop diuretics mainly act on the ascending branch of medullary loop and strongly inhibit the reabsorption of sodium, chlorine and potassium. Furosemide (furosemide) or bumetanide (butylamine) (40 times stronger than furosemide at the same dose) are commonly used for oral or intravenous injection. The effect is better if the drug is given immediately after the application of osmotic diuretics. Hyponatremia, hypokalemia and hypochloremia alkalosis should be avoided when using loop diuretics. (4) Osmotic diuretics can temporarily increase the osmotic pressure of plasma colloid and make the water in tissue absorbed back into the blood. In addition, they also pass through the glomerular filtration, resulting in the hypertonic state of the fluid in the renal tubules, reducing the reabsorption of water and sodium and diuresis. Sodium free dextran 40 (low molecular dextran) or starch substituted plasma (706 generation plasma) (molecular weight: 25000-45000) are commonly used for intravenous drip. The effect of diuresis can be enhanced by the use of loop diuretics. However, the patients with oliguria (urine volume < 400ml / D) should be cautious in the use of such drugs, because it is easy to form tubular with the tubular secretion of Tamm Horsfall protein and glomerular filtration albumin, blocking the renal tubules, and its hypertonic effect leads to degeneration and necrosis of renal tubular epithelial cells, inducing "osmotic nephropathy", leading to acute renal failure. (5) Increasing plasma colloid osmotic pressure, plasma or plasma albumin infusion can increase plasma colloid osmotic pressure, promote tissue water absorption and diuresis. If furosemide is added to glucose solution by slow intravenous drip, sometimes good diuretic effect can be obtained. However, the imported protein will be excreted from the urine within 24-48 hours, which can cause glomerular hyperfiltration and renal tubular hypermetabolism, cause damage to glomerular visceral layer and renal tubular epithelial cells, promote renal interstitial fibrosis, slightly affect the efficacy of glucocorticoid, delay disease remission, and seriously damage renal function. Therefore, the indications should be strictly controlled. For NS patients with severe hypoproteinemia, high edema and oliguria (urine volume < 400ml / D), it can be considered when diuresis is necessary, but too much frequency should also be avoided. Patients with heart failure should be cautious. 2. Reducing proteinuria. Persistent proteinuria itself can lead to glomerular hyperfiltration, aggravate tubulointerstitial injury and promote glomerulosclerosis, which is an important factor affecting the prognosis of glomerulopathy. It has been proved that reducing urinary protein can effectively delay the deterioration of renal function. Angiotensin converting enzyme inhibitor (ACEI) or angiotensin Ⅱ receptor antagonist (ARB), in addition to effective control of hypertension, can reduce glomerular pressure and directly affect the permeability of glomerular basement membrane to macromolecules, which has the effect of reducing urinary protein independent of lowering systemic blood pressure. When ACEI or ARB is used to reduce urinary protein, the dosage should be larger than that of conventional hypotension in order to obtain good curative effect.

Method 2: 1. Glucocorticoid treatment Glucocorticoid (hereinafter referred to as hormone) for kidney disease, mainly its anti-inflammatory effect. It can reduce the exudation of acute inflammation, stabilize lysosomal membrane, reduce the deposition of fibrin, reduce capillary permeability and reduce the leakage of urinary protein; in addition, it can inhibit the proliferation reaction in chronic inflammation, reduce the activity of fibroblasts, and reduce the fibrosis caused by tissue repair. The response of glucocorticoid to disease depends on its pathological type to a great extent, and the curative effect of minimal lesion is the most rapid and positive. The principle and plan of use are as follows: ① initial sufficient dosage: prednisone is commonly used for 8 weeks, and can be extended to 12 weeks if necessary; ② slow drug reduction; after sufficient treatment, 10% of the original dosage is reduced every 2-3 weeks; when the dosage is reduced to about 20 mg / D, the symptoms are easy to recur and should be reduced more slowly; ③ long-term maintenance: finally, the minimum effective dose is maintained for several months to six months. In order to reduce the side effects of hormone, the hormone can be taken in a full day or every other day during the maintenance period. If the edema is serious, liver function is damaged or the effect of prednisone is not good, it can be changed to oral prednisolone or intravenous prednisolone. According to the response of patients to glucocorticoid treatment, they can be divided into three types: "hormone sensitive type" (NS remission within 8-12 weeks), "hormone dependent type" (relapse after hormone reduction to a certain extent) and "hormone resistant type" (ineffective hormone treatment). The side effects such as infection, drug-induced diabetes and osteoporosis may occur in patients with long-term use of hormone, and aseptic avascular necrosis of femoral head may occur in a few cases, so it is necessary to strengthen the monitoring and timely treatment. 2. Cytotoxic drugs, hormone therapy is ineffective, or hormone dependent or recurrent, can be cytotoxic drugs to assist in the treatment. Because of the risk of gonadotropic toxicity, liver injury and high dose induced tumor, the indications and course of treatment should be carefully controlled. At present, cyclophosphamide and phenylbutyrate are widely used in clinic. 3. Immunosuppressants: Cyclosporine A, tacrolimus, mycophenolate mofetil and leflunomide are commonly used in clinic. In the past, immunosuppressants were often combined with glucocorticoids in the treatment of various pathological types of nephrotic syndrome. In recent years, it is also recommended that some patients who are relatively contraindicated or intolerable to glucocorticoids (such as uncontrolled diabetes, mental factors, severe osteoporosis), and some patients who are unwilling to accept glucocorticoid treatment or have contraindications should be treated alone Immunosuppressive therapy (including as the initial regimen) was used to treat some pathological types of nephrotic syndrome, such as focal segmental glomerulosclerosis, membranous nephropathy, minimal change nephropathy, etc.

matters needing attention

Usually, you can eat some high-quality high protein diet (animal protein), low salt and water limit, low-fat diet, pay attention to rest, avoid fatigue, prevent cold.