What does the diagnosis of renal failure during pregnancy mean? Chronic renal failure and pregnancy Acute renal failure in pregnant women

Acute renal failure(AKI) is a life-threatening complication of pregnancy. Pregnant women account for 15-20% of all cases of acute renal failure, which, as a rule, complicates the second half of pregnancy or the postpartum period. Acute renal failure is defined as a sharp drop in kidney function, accompanied in 80% of cases by oliguria. Proposed criteria for AKI include an increase in serum creatinine of at least 40 μmol/L per day. The absolute criterion is oliguria - a decrease in urine output of less than 400 ml/day.

Causes of acute renal failure during pregnancy

In the 60s of the XX century. the incidence of acute renal failure was 0.5 per 1000 pregnancies, currently in most countries of Europe and the United States does not exceed 1 per 20,000 births and accounts for less than 10% of all cases of acute renal failure, although in Asian countries this proportion remains high - from 15 to 20%. The frequency of deaths from acute renal failure among pregnant women has also changed; The mortality rate, which previously reached 56%, dropped to 10%. According to the World Health Organization, septic abortion (bacteremic and hemolytic shock) remains the main cause of acute renal failure (up to 40%) in developing countries. More than half of cases of acute renal failure in pregnant women, in addition to septic abortion, are associated with the development of severe forms of gestosis (preeclampsia/eclampsia, HELLP syndrome), profuse obstetric bleeding (premature placental abruption, hypotonic uterine bleeding). In 3-5% of cases, acute renal failure is caused by gestational pyelonephritis, in 15-20% - by intrauterine fetal death, embolism amniotic fluid and other reasons. In 10-15% of cases, acute renal failure is observed in women in the early postpartum period (hemolyticouremic syndrome, sepsis, transfusion complications).

Pathogenesis

A rare cause of acute renal failure caused by inflammation of the renal tissue during acute pyelonephritis in pregnant women is bacteremic shock and apostematous nephritis, which complicate pyelonephritis. Bacteremic shock is caused by the prescription of antibacterial therapy for pyelonephritis without previous restoration of urine passage; usually caused by gram-negative flora. Acute renal failure rapidly increases against the background of collapse, hypothermia, precomatose state, and DIC syndrome is often associated. In this case, vascular collapse is aggravated by acute adrenal insufficiency (due to hemorrhage into the adrenal glands), which can lead to acute tubular necrosis. In the diagnosis of bacteremic shock, it is important to establish occlusion of the urinary tract (calculus, necrotic papilla, etc.). In this case, treatment begins with restoring the outflow of urine using a catheter or nephrostomy, after which they switch to antibacterial therapy. An additional factor contributing to the deterioration of kidney function is drug nephrotoxicity of drugs.

Prerenal form and tubular necrosis are more typical for nephropathy in pregnant women.

Prerenal form

In prerenal (hypovolemic) acute renal failure, changes in urine tests are often absent; there may be an increased number of hyaline and granular casts; characterized by oliguria with a decrease in natriuresis (sodium concentration in urine less than 10 mmol/l), an increase in urine osmolarity, the ratio of urine creatinine to plasma creatinine over 10. Nitrogen excretory function of the kidneys is relatively preserved. The restoration of renal function is facilitated by rapid replenishment of blood volume.

Renal form

Acute tubular necrosis is manifested by severe oliguria and urinary syndrome (painless microhematuria, moderate proteinuria, cylindruria). The relative density of urine and the concentration of creatinine in it are sharply reduced, sodium excretion is increased. Azotemia quickly sets in. On ultrasound, the size of the kidneys is not reduced. Tubular necrosis is often completely or partially reversible.

Postrenal form

The incidence of urinary tract obstruction leading to acute renal failure in pregnant women suffering from bilateral nephrolithiasis or solitary kidney stones is practically no different from that in non-pregnant women. The clinical picture is characterized by pain in the lumbar region and/or gross hematuria, often with signs of urinary infection. The preferred diagnostic method is renal ultrasound, which reveals dilation and often stones. To eliminate obstruction, ureteral stents and percutaneous nephrostomy are used. Extremely rare causes of acute renal failure in pregnant women include compression of the ureters by an enlarged uterus, which is observed during twin pregnancy and polyhydramnios.

Cases of acute uric acid blockade of renal tubules as a cause of acute renal failure in pregnant women have been described (in these cases, the level of uric acid in the blood serum exceeded 700 µmol/l). Hydration, alkalization and forced diuresis with mannitol help restore renal function.

Acute renal failure in pregnant women is caused by diseases not related to pregnancy, among them are acute glomerulonephritis, CGN, interstitial nephritis, lupus nephritis, vasculitis, the occurrence and exacerbation of which is often observed in pregnant women. In these situations, a kidney biopsy is sometimes used to clarify the diagnosis and select therapeutic treatment tactics.

Treatment of acute renal failure during pregnancy

First of all, it is necessary to exclude the presence of hidden uterine bleeding, which is a trigger or provoking factor for acute renal failure, eliminate hemodynamic disturbances taking into account pathophysiological mechanisms, identify the cause and resolve the issue of indications for immediate delivery.
With a sufficient gestational age (over 30-34 weeks), rapid delivery is recommended, which eliminates growth retardation or intrauterine death of the fetus and improves the further prognosis for the mother.
With the development of preeclampsia and HELLP syndrome, regardless of the gestational age of the fetus, the only means to prevent the progression of the disease leading to the death of the mother is delivery. In situations that do not threaten the life of the mother, pregnancy may continue.
In case of prerenal acute renal failure in a pregnant woman, it is necessary first of all to eliminate hypovolemia - restore the intravascular volume of fluid by infusing an isotonic solution of sodium chloride, plasma, large-molecular dextrans, albumin; eliminate water and electrolyte disturbances, hypoproteinemia. Do not use drugs that can maintain hypovolemia (diuretics, non-steroidal anti-inflammatory drugs).
In acute tubular necrosis of pregnancy, treatment is aimed at combating ischemia (restoring blood supply to the kidneys), maintaining fluid and electrolyte balance, and eliminating infection. If there is no effect, hemodialysis or peritoneal dialysis is acceptable. It is recommended to carry out a dialysis regimen in which the blood urea level does not exceed 20 mmol/l and the uteroplacental circulation is not disturbed.
At the early stage of cortical necrosis, therapy is used, including anticoagulants (heparin, antithrombin III), antiplatelet agents (chirantil), exchange transfusions of native or fresh frozen plasma. If there is no effect, hemodialysis is used.
With the development of obstructive acute renal failure, restoration of urine passage is necessary; according to indications, massive antibacterial and detoxification therapy (gestational pyelonephritis), and the fight against vascular insufficiency when complicated by bacteremic shock.

Pregnancy is an amazing period in a woman’s life. Her body is changing, new ones are forming taste preferences and habits. However, the expectant mother’s body is not always able to bear a baby without medical help. Some serious disturbances in the functioning of the genitourinary system can lead to the fact that the kidneys simply stop functioning. Renal failure during pregnancy is a dangerous pathology that requires immediate intervention from specialists when diagnosed. Therefore, during pregnancy it is very important to closely monitor your health and undergo regular examinations.

Types of kidney failure

There are acute and chronic forms of the disease. In case of a chronic course, it is very important, even at the planning stage, to contact specialists who, based on the results of tests and studies, will be able to assess the chances of a successful pregnancy and childbirth. Unfortunately, medicine also knows cases when serious complications doctors were forced to terminate the pregnancy at an early stage to save the woman’s life. On later Emergency delivery is carried out in situations associated with the risk of bleeding in the mother and intrauterine fetal death, as well as in the presence of other abnormalities requiring surgical intervention.

Since the kidney is a kind of filter for the human body, additional load on this organ can lead to the appearance and development of diseases such as:

Pyelonephritis (kidney inflammation);
glomerulonephritis (damage to the glomeruli);
formation of stones and the presence of sand in the kidneys and ureter;
cystitis (bladder infection).

All of the above painful conditions can provoke acute renal failure in pregnant women. The development of this type of disease is most often diagnosed in the first and last trimester. Depending on the symptoms, prerenal, renal and postrenal forms are determined.

Signs of the disease

In addition to pain in the area where the kidneys are located, against the background of a general deterioration in well-being, swelling of the lower extremities, drowsiness, and fatigue are also possible. Complaints of severe headache and high blood pressure, difficult and painful urination, dry mouth, nausea and repeated vomiting, in turn, are a reason to immediately contact the antenatal clinic or the nearest clinic. If a patient with a history of any diseases, one way or another related to the kidneys, is not promptly provided with all the necessary assistance for such symptoms, then the probability of death is almost 100%. Failure of one or both kidneys simultaneously leads to severe intoxication of the body. The state of pregnancy against the background of the general clinical picture only aggravates the situation.

Establishing diagnosis

Kidney failure during pregnancy can be determined by several types of tests. Typically, a urologist writes out referrals for a general blood and urine test, blood biochemistry and urine microbiology. Ultrasound diagnostics is also a mandatory item on this list. Ultrasound helps identify kidney and bladder diseases at their initial stages.

Treatment methods

After the disease is diagnosed, the doctor will prescribe complex therapy. Since not all medications intended to relieve pain and eliminate the causes of their occurrence can be used while waiting for a baby, urologists are very careful when prescribing many medications. The main methods of treatment in this case are:

Nutrition adjustments. In case of kidney failure, patients are advised to drink at least 2 liters of water daily and eat foods that are easily absorbed by the body. It is advisable to exclude white bread products and products rich in potassium from the diet.
Medication support. To prevent the consequences of intoxication, drugs are used that remove toxins from the body. "Canephron" and "Brusniver" have an anti-inflammatory effect and do not have any negative influence for the fruit However, this does not mean that you can take them on your own!

It is strictly prohibited to use any medicines on your own initiative!

Unfortunately, the chronic form of the disease cannot be cured. To relieve symptoms and stabilize the general condition of the body, the doctor may prescribe systematic dialysis. In addition, the patient is strictly prohibited from any type of physical activity and bed rest is indicated in case of exacerbation.

Complications of kidney failure

Delayed diagnosis can lead to the acute form of the disease progressing to an incurable (chronic) stage. In addition to such disappointing prognoses, there is a risk of developing uremic coma and sepsis.

Even if a woman has no apparent reason to worry, planning a pregnancy is an ideal scenario. With this approach, you can avoid many serious health problems even before conception, because the expectant mother is responsible not only for herself, but also for the little representative of the new generation.

Renal failure during pregnancy or the postpartum period may be associated with deterioration of kidney function due to pre-existing or pregnancy-induced kidney disease.

There are prerenal, renal and postrenal causes of renal failure during pregnancy.

Prerenal include dehydration or blood loss as a result of obstetric hemorrhage, which are easily diagnosed.
Renal causes are usually suggested in patients with a history of kidney disease, as well as hypercoagulability (for example, against the background of thrombotic thrombocytopenic purpura or hemolytic-uremic syndrome). Prolonged hypotension can cause the development of acute cortical or tubular necrosis.
Postrenal causes are detected less frequently, but they should be assumed in case of obstructive processes in the urinary tract, or with a history of urolithiasis.

Laboratory research

Laboratory tests for renal failure during pregnancy are aimed at assessing renal function, the cardiovascular system and urinary tract patency.

Kidney tests. Renal tests include monitoring daily diuresis, determining the ratio of urea and creatinine in the blood, fractional excretion of sodium and urine osmolality. Oliguria is considered to be a urine output of less than 25 ml/h, while anuria is a complete cessation of urination. Often, a decrease in diuresis signals an impending severe impairment of kidney function. During pregnancy, the blood urea to creatinine ratio and creatinine concentration decrease, but their ratio remains within 20:1. Its increase indicates tubular hypoperfusion (prerenal renal failure).

A urine osmolality greater than 500 mOsm/L or a urine-to-plasma osmolality ratio greater than 1.5:1 also indicates renal hypoperfusion. The relative density of urine is not of great importance, especially if protein or hemolyzed blood is detected in it.

Study of the functions of the cardiovascular system. Acute and dehydration are usually accompanied by orthostatic hypotension, tachycardia, decreased skin turgor and decreased sweating. In women with hypertension or during labor, these signs often go unrecognized. According to indications, a Swan-Ganz catheter is installed, which allows monitoring the filling pressure of the right and left ventricles, cardiac output and wedge pressure in the capillaries of the pulmonary artery. This helps differentiate between conditions such as congestive heart failure, cardiac tamponade, and volume depletion, all of which can cause acute renal failure.

Examination of the urinary tract. To diagnose obstruction, catheterization of the bladder with a Foley catheter and the kidneys is usually sufficient. Sometimes a single intravenous pyelography is required. It is important to differentiate physiological hydronephrosis of pregnancy from true obstruction.

Treatment

Prerenal causes. To eliminate oliguria, normalization of intravascular volume, cardiac output and blood pressure is achieved. Special attention attention should be paid to the correction of electrolyte disturbances when administering large volumes of crystalloids.

Renal reasons. Acute tubular and/or cortical necrosis may develop. Since cortical necrosis is usually irreversible, treatment is aimed at preventing further kidney damage. The use of diuretics to increase urine output helps reduce the duration and severity of acute tubular necrosis and increase survival in women. Furosemide is administered immediately, which is then re-administered every 4-6 hours for 48 hours (provided that urination is complete). If there is no effect from diuretic therapy, oliguria (less than 500 ml/day) is diagnosed and infusion therapy is started. Fluid intake should exceed urine output and insensible fluid losses. Renal function is assessed daily. During the first few days after an episode of renal ischemia, renal function deteriorates, but over the next 7-10 days, in most cases of acute tubular necrosis, it improves significantly. If deterioration develops quickly and there are no signs of improvement, hemodialysis is recommended.

When acute renal failure is combined with oliguria, the diuretic phase coincides with the recovery period. Diuresis can exceed 10 L/day, and if electrolyte losses are not properly corrected, the patient will die. In approximately 50% of cases of acute renal failure that developed before childbirth or in the postpartum period, kidney function is almost completely restored without hemodialysis during the first year.

Postrenal causes. Often, disorders can be corrected by such simple techniques as turning the woman on her left side, shifting the pregnant uterus away from the ureters, and inserting a Foley catheter to relieve urethral obstruction. If there is obstruction of the ureters or renal pelvis (for example, by stones), surgical intervention is performed to restore the outflow of urine.

Chronic renal failure and pregnancy

The outcome of pregnancy complicated by chronic kidney disease is less favorable. The best prognosis is observed with minor renal dysfunction. The risk of adverse fetal and renal outcomes increases with the severity of renal failure. An increase in creatinine concentration over 150-200 mmol/l (especially in combination with hypertension or neurotic syndrome) worsens the prognosis for renal failure during pregnancy for the mother and fetus. Treatment of renal failure during pregnancy includes regular monitoring of renal function, including determination of creatinine clearance, protein content in 24-hour urine, and screening for asymptomatic bacteriuria. To prevent further kidney damage, diastolic pressure should be maintained at 90 mm Hg. or lower. The addition of preeclampsia to the background of the patient’s existing hypertension is quite difficult to diagnose. Fetal observation is carried out to assess its development and condition.

Pregnancy after kidney transplant

After a kidney transplant, a woman can plan a pregnancy only after a thorough assessment of the risks to herself, the fetus and the newborn. Patients with a kidney transplant often experience hypertension (up to 70%) and preeclampsia. In approximately 14% of cases, the functioning of the graft significantly deteriorates or it is rejected. Fetal complications include glucocorticoid-induced adrenal and liver failure, prematurity, and. Moreover, the child may inherit primary kidney disease from the mother or other family members. Mother and newborn have high risk the occurrence of infectious complications, which is associated with immunosuppressive therapy.

The most suitable time for pregnancy is 1-2 years after transplantation, provided that the kidneys are functioning stable (with a blood creatinine concentration of less than 150 mmol/l, proteinuria less than 500 mg/day), the absence of severe hypertension and taking low doses of prednisone and constant doses of azathioprine and cyclosporine. These drugs do not have a pronounced teratogenic effect, but their long-term effect on growth, immune system And mental development child is unknown. Cyclosporine may have side effects on the mother's body in the form of increased blood pressure, deterioration of kidney function, hyperglycemia, hyperuricemia and, less commonly, hemolytic-uremic syndrome.

The article was prepared and edited by: surgeon

Keywords

CHRONIC KIDNEY DISEASE / CHRONIC RENAL FAILURE/ PREGNANCY / CHRONIC KIDNEY DISEASE / CHRONIC RENAL FAILURE / PREGNANCY

annotation scientific article on clinical medicine, author of the scientific work - Nikolskaya Irina Georgievna, Prokopenko Elena Ivanovna, Novikova Svetlana Viktorovna, Budykina Tatyana Sergeevna, Kokarovtseva Svetlana Nikolaevna

Pregnancy in women with kidney disease, even with preserved renal function, is accompanied by an increased frequency of obstetric and perinatal complications compared to population indicators, such as preeclampsia, premature birth, the need for surgical delivery, and intensive care for newborns. The article presents our own data on complications and pregnancy outcomes in 156 women with different stages chronic kidney disease(CKD). Of these, 87 patients were with CKD stage I, 29 with CKD stage II and 40 with CKD stages III, IV, V, combined into the diagnosis " chronic renal failure"(CRF). For the first time in Russia, the authors summarized the unique experience of managing pregnancy with chronic renal failure, emphasized the high probability (27.5%) of its primary diagnosis during pregnancy, presented algorithms for the examination, prevention and treatment of various gestational complications in chronic renal failure (preeclampsia, urinary tract infections, fetoplacental insufficiency, anemia, acute kidney injury), as well as the effect of pregnancy on kidney function in the late postpartum period. A direct correlation has been proven between the stage of CKD, the incidence of preeclampsia, fetoplacental insufficiency, premature birth, surgical delivery by cesarean section, and the condition of children at birth. Based on large clinical material, the likelihood of a favorable pregnancy outcome in patients with chronic renal failure with stable renal function and in the absence of severe arterial hypertension during pregnancy: for the child in 87%, for the mother in 90% (maintaining the same stage of CKD). The risk of persistent decline in kidney function during pregnancy and the postpartum period in women with chronic renal failure increases with stage IV CKD and in the case of early onset of preeclampsia, and also correlates with its severity. The likelihood of a favorable obstetric and “nephrological” outcome increases when planning pregnancy and intensive joint management of patients by an obstetrician-gynecologist and a nephrologist with early dates pregnancy

Complications and outcomes of pregnancy in chronic kidney disease

Pregnancy in women with kidney disorders, even with preserved renal function, is associated with higher than in the population rates of obstetric and perinatal complications, such as eclampsia, preterm delivery, surgical deliveries and intensive care for newborns. This article presents our own data on complications and outcomes of pregnancies in 156 women with various stages of chronic kidney disease (CKD). From these, 87 patients had CKD stage I, 29 with CKD stage II and 40 with CKD stages III, IV, V. For the first time in Russia, the authors summarize their unique experience in management of pregnancy with CKD, underline a high probability (27.5%) of its primary detection during pregnancy, discuss the algorithms of assessment, prevention and treatment of various gestational complications in CKD (pre-eclampsia, urinary tract infections, feto-placental insufficiency, anemia, acute renal damage), as well as the influence of pregnancy on renal function at long-term post-delivery. A direct correlation between the CKD stage, frequency of pre-eclampsia, feto-placental insufficiency, preterm deliveries, surgical deliveries by caesarean section and babies"" status at birth is demonstrated. Based on their ample clinical material, they confirm the probability of favorable pregnancy outcomes in CKD patients with stable renal function without severe arterial hypertension during pregnancy: for a baby in 87%, for the mother in 90% (maintenance of the same CKD stage). The risk of persistent deterioration of renal function during pregnancy and puerperium in women with CKD is higher in CKD stage IV, as well as in the case of early development of pre-eclampsia; it also correlates with severity of the latter. The probability of a favorable obstetric and nephrological outcome is higher when the pregnancy is planned and intensively co-managed by an obstetrician/gynaecologist and a nephrologist from early weeks of gestation onwards.

Modern medicine manages to cope with most acute kidney diseases and curb the progression of most chronic ones. Unfortunately, until now, about 40% of renal pathologies are complicated by the development of chronic renal failure (CRF).

This term means the death or replacement by connective tissue of part of the structural units of the kidneys (nephrons) and irreversible impairment of the kidneys’ functions to cleanse the blood of nitrogenous wastes, produce erythropoietin, which is responsible for the formation of red blood elements, remove excess water and salts, and reabsorb electrolytes.

The consequence of chronic renal failure is a disorder of water, electrolyte, nitrogen, acid-base balance, which entails irreversible changes in the state of health and often becomes the cause of death in terminal chronic renal failure. The diagnosis is made when disorders are registered for three months or longer.

Today, CKD is also called chronic kidney disease (CKD). This term emphasizes the potential for the development of severe forms of renal failure even in the initial stages of the process, when the glomerular filtration rate (GFR) has not yet been reduced. This allows for more careful attention to patients with asymptomatic forms of renal failure and improves their prognosis.

Criteria for chronic renal failure

The diagnosis of chronic renal failure is made if the patient has one of two types of renal disorders for 3 months or more:

Damage to the kidneys with disruption of their structure and function, which are determined by laboratory or instrumental diagnostic methods. In this case, GFR may decrease or remain normal.
There is a decrease in GFR of less than 60 ml per minute in combination with or without kidney damage. This rate of filtration corresponds to the death of about half of the nephrons of the kidneys.

What leads to chronic renal failure

Almost any chronic illness kidney disease without treatment can sooner or later lead to nephrosclerosis with the failure of the kidneys to function normally. That is, without timely treatment, such an outcome of any kidney disease such as chronic renal failure is just a matter of time. However, cardiovascular pathologies, endocrine diseases, and systemic diseases can lead to renal failure.

Kidney diseases: chronic glomerulonephritis, chronic tubulointerstitial nephritis, renal tuberculosis, hydronephrosis, polycystic kidney disease, nephrolithiasis.
Pathologies of the urinary tract: urolithiasis, urethral strictures.
Cardiovascular diseases: arterial hypertension, atherosclerosis, incl. angiosclerosis of the renal vessels.
Endocrine pathologies: diabetes.
Systemic diseases: renal amyloidosis, .

How does chronic renal failure develop?

The process of replacing the affected glomeruli of the kidney with scar tissue is simultaneously accompanied by functional compensatory changes in the remaining ones. Therefore, chronic renal failure develops gradually, passing through several stages in its course. The main reason for pathological changes in the body is a decrease in the rate of blood filtration in the glomerulus. The normal glomerular filtration rate is 100-120 ml per minute. An indirect indicator by which one can judge GFR is blood creatinine.

The first stage of chronic renal failure is initial

At the same time, the glomerular filtration rate remains at the level of 90 ml per minute (normal variant). There is confirmed kidney damage.

Second stage

It suggests kidney damage with a slight decrease in GFR in the range of 89-60. For older people, in the absence of structural damage to the kidneys, such indicators are considered normal.

Third stage

In the third moderate stage, GFR drops to 60-30 ml per minute. At the same time, the process occurring in the kidneys is often hidden from view. There is no bright clinic. There may be an increase in the volume of urine excreted, a moderate decrease in the number of red blood cells and hemoglobin (anemia) and associated weakness, lethargy, decreased performance, pale skin and mucous membranes, brittle nails, hair loss, dry skin, decreased appetite. About half of the patients experience an increase in blood pressure (mainly diastolic, i.e. lower).

Fourth stage

It is called conservative because it can be restrained medicines and just like the first, it does not require blood purification using hardware methods (hemodialysis). At the same time, glomerular filtration is maintained at a level of 15-29 ml per minute. Clinical signs of renal failure appear: severe weakness, decreased ability to work due to anemia. The volume of urine excreted increases, significant urination at night with frequent urges at night (nocturia). Approximately half of patients suffer from high blood pressure.

Fifth stage

The fifth stage of renal failure is called terminal, i.e. final. When glomerular filtration decreases below 15 ml per minute, the amount of urine excreted drops (oliguria) until it is completely absent in the outcome of the condition (anuria). All signs of poisoning of the body with nitrogenous wastes (uremia) appear against the background of water-electrolyte imbalance, damage to all organs and systems (primarily the nervous system, heart muscle). With this development of events, the patient’s life directly depends on blood dialysis (cleaning it bypassing non-functioning kidneys). Without hemodialysis or kidney transplantation, patients die.

Symptoms of chronic renal failure

Appearance of patients

The appearance does not suffer until the stage when glomerular filtration is significantly reduced.

Due to anemia, pallor appears, due to water and electrolyte disturbances, dry skin.
As the process progresses, yellowness of the skin and mucous membranes appears and their elasticity decreases.
Spontaneous bleeding and bruising may occur.
This causes scratching.
Characterized by so-called renal edema with puffiness of the face, up to the common type of anasarca.
The muscles also lose tone and become flabby, which causes fatigue to increase and the ability of patients to work decreases.

Nervous system lesions

This is manifested by apathy, night sleep disorders and daytime sleepiness. Decreased memory and learning ability. As chronic renal failure increases, severe inhibition and disturbances in the ability to remember and think appear.

Disturbances in the peripheral part of the nervous system affect the limbs with chilliness, tingling sensations, and crawling sensations. Later, movement disorders in the arms and legs develop.

Urinary function

She first suffers from polyuria (increased urine volume) with a predominance of nighttime urination. Further, chronic renal failure develops along the path of a decrease in urine volume and the development of edematous syndrome until the complete absence of excretion.

Water-salt balance

salt imbalance manifests itself as increased thirst, dry mouth
weakness, darkening of the eyes when standing up suddenly (due to sodium loss)
Excess potassium may cause muscle paralysis
breathing problems
slowing of heartbeats, arrhythmias, intracardiac blockades up to cardiac arrest.

Against the background of increased production of parathyroid hormone by the parathyroid glands, a high level of phosphorus appears and low level calcium in the blood. This leads to softening of the bones, spontaneous fractures, and itchy skin.

Nitrogen balance disorders

They cause an increase in blood creatinine, uric acid and urea, resulting in:

when GFR is less than 40 ml per minute, enterocolitis develops (damage to the small and large intestines with pain, bloating, frequent loose stools)
ammonia odor from the mouth
secondary articular lesions such as gout.

The cardiovascular system

firstly, it responds by increasing blood pressure
secondly, damage to the heart (muscles - pericarditis, pericarditis)
Dull pain in the heart, heart rhythm disturbances, shortness of breath, swelling in the legs, and enlarged liver appear.
If myocarditis progresses unfavorably, the patient may die due to acute heart failure.
pericarditis can occur with the accumulation of fluid in the pericardial sac or the loss of uric acid crystals in it, which in addition to pain and expansion of the boundaries of the heart, when listening chest gives a characteristic (“funeral”) friction noise of the pericardium.

Hematopoiesis

Against the background of a deficiency in the production of erythropoietin by the kidneys, hematopoiesis slows down. The result is anemia, which manifests itself very early in weakness, lethargy, and decreased performance.

Pulmonary complications

characteristic of late stages of chronic renal failure. This is uremic lung - interstitial edema and bacterial inflammation of the lung against the background of a decrease in immune defense.

Digestive system

She reacts with decreased appetite, nausea, vomiting, inflammation of the oral mucosa and salivary glands. With uremia, erosive and ulcerative defects of the stomach and intestines appear, fraught with bleeding. Acute hepatitis is a frequent accompaniment of uremia.

Kidney failure during pregnancy

Even a physiologically occurring pregnancy significantly increases the load on the kidneys. In chronic kidney disease, pregnancy aggravates the course of the pathology and can contribute to its rapid progression. This is due to the fact that:

during pregnancy, increased renal blood flow stimulates overstrain of the renal glomeruli and the death of some of them,
deterioration of conditions for reabsorption of salts in the renal tubules leads to losses of high volumes of protein, which is toxic to renal tissue,
increased functioning of the blood coagulation system contributes to the formation of small blood clots in the capillaries of the kidneys,
worsening arterial hypertension during pregnancy contributes to glomerular necrosis.

The worse the filtration in the kidneys and the higher the creatinine numbers, the more unfavorable the conditions for pregnancy and its gestation. A pregnant woman with chronic renal failure and her fetus face a number of pregnancy complications:

Arterial hypertension
Nephrotic syndrome with edema
Preeclampsia and eclampsia
Severe anemia
and fetal hypoxia
Delays and malformations of the fetus
and premature birth
Infectious diseases of the urinary system of a pregnant woman

To resolve the issue of the advisability of pregnancy for each specific patient with chronic renal failure, nephrologists and obstetricians-gynecologists are involved. In this case, it is necessary to assess the risks for the patient and the fetus and correlate them with the risks that the progression of chronic renal failure every year reduces the likelihood of a new pregnancy and its successful resolution.

Treatment methods

The beginning of the fight against chronic renal failure is always the regulation of diet and water-salt balance

Patients are recommended to eat a diet limiting their protein intake to 60 grams per day and predominantly consuming plant proteins. As chronic renal failure progresses to stage 3-5, protein is limited to 40-30 g per day. At the same time, the proportion of animal proteins is slightly increased, giving preference to beef, eggs and lean fish. The egg-potato diet is popular.
At the same time, the consumption of foods containing phosphorus (legumes, mushrooms, milk, white bread, nuts, cocoa, rice) is limited.
Excess potassium requires reducing the consumption of black bread, potatoes, bananas, dates, raisins, parsley, figs).
Patients have to manage with a drinking regimen of 2-2.5 liters per day (including soup and taking pills) in the presence of severe edema or intractable arterial hypertension.
It is useful to keep a food diary, which makes it easier to track the protein and microelements in food.
Sometimes specialized mixtures, enriched with fats and containing a fixed amount of soy proteins and balanced in microelements, are introduced into the diet.
Along with the diet, patients may be prescribed an amino acid substitute - Ketosteril, which is usually added when GFR is less than 25 ml per minute.
A low-protein diet is not indicated for exhaustion, infectious complications of chronic renal failure, uncontrolled arterial hypertension, with GFR less than 5 ml per minute, increased protein breakdown, after surgery, severe nephrotic syndrome, terminal uremia with damage to the heart and nervous system, and poor diet tolerance.
Salt is not limited to patients without severe arterial hypertension and edema. In the presence of these syndromes, salt is limited to 3-5 grams per day.

Enterosorbents

They can somewhat reduce the severity of uremia by binding in the intestines and removing nitrogenous wastes. This works for early stages CRF with relative preservation of glomerular filtration. Polyphepan, Enterodes, Enterosgel, Activated carbon, are used.

Treatment of anemia

To relieve anemia, Erythropoietin is administered, which stimulates the production of red blood cells. Uncontrolled arterial hypertension becomes a limitation to its use. Since iron deficiency may occur during treatment with erythropoietin (especially in menstruating women), therapy is supplemented with oral iron supplements (Sorbifer Durules, Maltofer, etc., see).

Bleeding disorder

Correction of blood clotting disorders is carried out with Clopidogrel. Ticlopedin, Aspirin.

Treatment of arterial hypertension

Drugs for the treatment of arterial hypertension: ACE inhibitors (Ramipril, Enalapril, Lisinopril) and sartans (Valsartan, Candesartan, Losartan, Eprosartan, Telmisartan), as well as Moxonidine, Felodipine, Diltiazem. in combinations with saluretics (Indapamide, Arifon, Furosemide, Bumetanide).

Phosphorus and calcium metabolism disorders

It is stopped with calcium carbonate, which prevents the absorption of phosphorus. Lack of calcium - synthetic vitamin D preparations.

Correction of water and electrolyte disorders

is carried out in the same way as the treatment of acute renal failure. The main thing is to relieve the patient from dehydration due to restrictions in the diet of water and sodium, as well as eliminating blood acidification, which is fraught with severe shortness of breath and weakness. Solutions with bicarbonates and citrates, sodium bicarbonate are introduced. A 5% glucose solution and Trisamine are also used.

Secondary infections in chronic renal failure

This requires the prescription of antibiotics, antiviral or antifungal drugs.

Hemodialysis

With a critical decrease in glomerular filtration, blood purification from substances of nitrogen metabolism is carried out by hemodialysis, when waste products pass into the dialysis solution through a membrane. The most commonly used device is the “artificial kidney”, less often peritoneal dialysis is performed, when the solution is poured into abdominal cavity, and the role of the membrane is played by the peritoneum. Hemodialysis for chronic renal failure is carried out in a chronic mode. For this, patients travel for several hours a day to a specialized center or hospital. In this case, it is important to prepare an arteriovenous shunt in a timely manner, which is prepared at a GFR of 30-15 ml per minute. Once the GFR drops below 15 ml, dialysis begins in children and patients with diabetes mellitus, with GFR less than 10 ml per minute, dialysis is performed in other patients. In addition, indications for hemodialysis will be:

Severe intoxication with nitrogenous products: nausea, vomiting, enterocolitis, unstable blood pressure.
Treatment-resistant edema and electrolyte disturbances. Cerebral edema or pulmonary edema.
Severe blood acidification.

Contraindications to hemodialysis:

bleeding disorders
persistent severe hypotension
tumors with metastases
decompensation of cardiovascular diseases
active infectious inflammation
mental illness.

Kidney transplant

This is a radical solution to the problem of chronic kidney disease. After this, the patient has to use cytostatics and hormones for life. There are cases of repeated transplants if for some reason the graft is rejected. Renal failure during pregnancy with a transplanted kidney is not an indication for termination of pregnancy. pregnancy can be carried to the required term and is resolved, as a rule, caesarean section at 35-37 weeks.

Thus, Chronic kidney disease, which today has replaced the concept of “chronic renal failure,” allows doctors to see the problem in a more timely manner (often when there are still no external symptoms) and respond by starting therapy. Adequate treatment can prolong or even save the patient’s life, improve his prognosis and quality of life.