How is chronic renal failure treated?

Before the treatment of a patient with chronic renal insufficiency, it is necessary to determine the disease that led to the development of renal failure, the stage and the main clinical and laboratory symptoms of impaired renal function. An unambiguous interpretation of these important indicators, and hence the use of identical terminological and diagnostic approaches, is considered important for the tactics of conducting.

Patients with chronic renal insufficiency need correction of diet and syndrome treatment.

A high-calorie diet with a low protein content is recommended, which helps prevent protein-energy deficiency.

Low protein diet. Protein metabolism products play an important role in the immune and non-immune mechanisms of the progression of chronic renal failure (an increase in renal plasmotok, leading to hemodynamic disorders). Observance of a low-protein diet at early stages of renal failure helps to reduce excess phosphorus concentration and slow the development of secondary hyperparathyroidism and renal osteodystrophy. However, it is not recommended to sharply reduce the protein content in the diet of children (as opposed to adults). In children, depending on the age, sex and degree of severity of chronic renal failure, it should be from 0.6 to 1.7 g / kg body weight per day (70% - animal protein).

In order to prevent protein-energy insufficiency (BEN), the risk of developing it in children with chronic renal insufficiency is higher than in adults, and with the forced exclusion from the diet of a number of products, their full replacement with others equivalent in food and biological value is necessary. It is recommended to use ketoanalogues of amino acids, as well as inclusion of soy products in the diet.

Hypophosphate diet. Gipofosfatnuyu diet should be observed with GFR less than 50 ml / min, while the content of phosphorus in the daily diet should not exceed 800-1000 mg. To products rich in phosphates, include milk and dairy products, beans, soy, beans, peas, lentils, protein foods (eggs, lamb, poultry, liver, liver, salmon, sardines, cheeses), bread and cereals (corn bread , barley, bran, wafers), chocolate, nuts.

Since it is difficult for children to observe a hypophosphate diet, starting with the early stages of chronic kidney failure, with a daily food content of more than 1 g of phosphate, the substances binding them are prescribed.

Medication for chronic renal failure

• Conservative treatment of renal failure begins already at the early stages of its development and is determined by the severity of the underlying disease and chronic kidney failure, the presence of complications from other organs and systems.
• Children with long-term renal diseases and lowering the clearance of endogenous creatinine below 70 ml / min are eligible for follow-up at the nephrologist.
• For a small decrease in the content of nitrogenous slags in the serum, enterosorbents can be used that bind creatinine, urea and other toxic products secreted in the digestive tract. Absolute contraindication to the appointment of sorbents - ulcerative process and / or bleeding in the gastrointestinal tract.
• Treatment should include measures to prevent osteodystrophy: regular monitoring of the concentration of Ca ² parathyroid hormone, phosphates, alkaline phosphatase activity from early stages of chronic kidney disease in children (with GFR <60 ml / min), administration of calcium preparations in combination with active metabolites of vitamin D ₃.
• The main measures for the prevention and treatment of osteodystrophy in patients receiving renal replacement therapy:
  • maintenance of normal concentration of calcium in the blood;
  • ensuring adequate calcium content in dialysis fluid;
  • reduction of phosphate intake with food;
  • the use of substances that bind phosphates;
  • the appointment of active forms of metabolites of vitamin D ₃;
  • correction of acidosis;
  • complete purification of water used to prepare a solution for hemodialysis.
• The appointment of vitamin D preparations before the emergence of obvious signs of hyperparathyroidism (hypocalcemia, increase in the concentration of parathyroid hormone, activity of alkaline phosphatase in the blood), which contributes to the prevention of osteodystrophy and satisfactory development of the child. For the successful treatment and prevention of renal osteodystrophy, the content of parathyroid hormone should be within the normal range of the pre-dialysis stage and be 150-250 pg / ml in children on dialysis.

• The use of ACE inhibitors helps prevent the progression of sclerotic changes in the kidneys due to a decrease in renal hyperperfusion and a decrease in blood pressure. Consequently, ACE inhibitors in combination with angiotensin receptor antagonists, beta-adrenoblockers and slow calcium channel blockers can be attributed to the basic therapy of hypertension. For example, captopril orally in 0.3-0.5 mg / kg in 2-3 doses or enalapril oral 0.1-0.5 mg / kg 1 time per day for a long time (under the control of blood pressure).
• Early correction of anemia, allowing to provide a reduction in the left ventricular mass index in patients in the pre-dialysis and dialysis stage of chronic renal failure. Treatment with erythroletin beta is initiated if the concentration of hemoglobin does not exceed 110 g / l when re-examined. The lack of effect or lack of response to treatment with erythropoietin beta is usually due to absolute or functional iron deficiency. Its drugs are recommended to appoint all patients with anemia.
• Patients with chronic renal insufficiency in the pre-dialysis and dialysis period with a hemoglobin content of less than 110 g / l may receive the following treatment regimen: erythropoietin beta subcutaneously 2-3 times per week in a weekly dose of 50-150 IU / kg under the control of the concentration of hemoglobin, hematocrit, determined once in 2-4 weeks. If necessary, a single dose is increased once every 4 weeks by 25 units / kg until the optimal concentration of hemoglobin is reached. Then a maintenance dose is prescribed: in children weighing less than 10 kg, 75-150 units / kg (about 100 units / kg); 10-30 kg - 60-150 units / kg (about 75 units / kg); more than 30 kg - 30-100 units / kg (about 33 units / kg). At the same time, iron preparations (trivalent) are prescribed.

The goal of the treatment is to increase the concentration of hemoglobin by 10-20 g / l per month. If after the start of treatment with erythropoietin beta or after the next dose increase, the hemoglobin content increases by less than 7 g / l for 2-4 weeks, then the dose of the drug is increased by 50%. If the absolute increase in hemoglobin concentration after the start of treatment exceeds 25 g / l per month or its content exceeds the target, the weekly dose of erythropoietin beta is reduced by 25-50%.

Renal Replacement Therapy for Chronic Renal Failure

The problem of replacing lost kidney functions in children is complex and has not been resolved to date in the world. This is due to the technical difficulty of performing a kidney transplantation for a small child and creating a long-term functioning vascular access for hemodialysis, as well as the difficulty of drug substitution of lost humoral functions of the kidneys. Decision-making on renal replacement therapy should be timely in order to prevent irreversible effects of uremia for the musculoskeletal system, delay in the development of the child and damage to internal organs.

Indications for the beginning of renal replacement therapy in children with chronic renal failure:

• GFR less than 10.5 ml / min;
• the emergence of symptoms of uremia and its complications: pericarditis, nausea, vomiting, edema resistant to treatment, severe acidosis, blood clotting disorders, neuropathy, severe PEM with GFR less than 15-20 ml / min.

The nephrological service should be able to use all three methods of renal replacement therapy (peritoneal dialysis, hemodialysis and kidney transplantation), which will allow choosing the optimal method for the patient.

For high-grade hemodialysis, sessions of 4-5 hrs 3 times per week are necessary, provided that the process is carefully controlled, especially in children and patients with unstable hemodynamics.

There are no absolute contraindications to hemodialysis, but there are cases when the session is impossible for technical reasons.

Contraindications to hemodialysis:

• small weight of the child's body and the impossibility in this connection to exercise vascular access to ensure adequate blood flow;
• cardiovascular failure;
• hemorrhagic syndrome (the risk of severe bleeding on the background of heparinization).

In these situations, peritoneal dialysis is indicated. Peritoneal access in children is easy to perform. Complications associated with a catheter are usually not life threatening. Permanent ambulatory peritoneal dialysis performed at home by parents, the procedure is painless and takes little time. Periodically (once every 2 weeks) perform a blood test, as well as an examination of the patient in the clinic.

Advantages of peritoneal dialysis:

• There are fewer restrictions on the selection of sick children compared with hemodialysis (especially the age and weight of the child);
• In patients with peritoneal dialysis, the residual renal function was better preserved than in hemodialysis patients. That is why peritoneal dialysis is more suitable for patients with a significant residual function of the kidneys and the possibility of its recovery;
• According to the literature, the best results of kidney transplantation were noted in patients on peritoneal dialysis;
• peritoneal dialysis provides a higher quality of life: children can live at home, attend school, lead an active lifestyle.

As a starting method of treatment, it is preferable to use peritoneal dialysis, which helps maintain residual kidney function and is more favorable for the cardiovascular system.

Contraindications for peritoneal dialysis:

• leakage of the abdominal cavity (presence of ileostom, drainage, early periods after laparotomy);
• Adhesive process and tumor formations in the abdominal cavity, limiting its volume;
• purulent infection of the abdominal wall or peritonitis.

Dialysis in children with chronic kidney failure is usually started only for the purpose of subsequent kidney transplantation, as the length of the child's stay on dialysis is limited. It should be remembered that in combination with drug treatment, it does not fill the lost humoral functions of the kidneys. That is why it is desirable that the waiting time for transplantation does not exceed 1-2 years, and with increasing lag in physical development, the increase in symptoms of renal osteodystrophy was significantly less.

Kidney transplantation is the optimal method for correcting the terminal stage of chronic kidney failure in a child. Absolute contraindications to transplantation in children do not exist. Relative, temporary contraindications requiring treatment and dialysis include malignant neoplasms and some diseases accompanied by a high risk of recurrence in the transplant. The main source of organs for children is adult donors. The size of the kidney of an adult person allows you to transplant her child even to a younger age. Threshold indicators of the child, after which the kidney can be transplanted from an adult donor, is considered to be 70 cm in height and 7 kg in weight. For kidney transplantation, both cadaveric and living related donors are used. They should be compatible with the recipient for the blood group, have a negative crossover lymphocytotoxic test (no cytolysis when combining donor and serum lymphocytes. The recipient). It is desirable that the antigens of the main histocompatibility complex (HLA) coincide.

After kidney transplantation, the child should receive immunosuppressive therapy aimed at prevention of rejection during the whole period of the transplant functioning. The main principle of the regime of immunosuppression is the combination of 2-3 drugs in small doses. Their choice depends on the presence and severity of side effects. Based on these principles, the child is selected a mode of immunosuppression, not accompanied by significant side effects and not affecting the quality of life.

Evaluation of treatment effectiveness

The effective treatment of chronic renal failure is indicated by the absence of a progressive increase in the concentration of creatinine and urea nitrogen in the blood, anemia, osteodystrophy and other complications of chronic renal failure, normal development and satisfactory well-being of patients.

Prognosis for chronic renal failure

Each of the methods of renal replacement therapy is characterized by a certain period of survival, and transplantation is also considered not a final, but only one of the stages of treatment. After loss of the function of the transplant, it is possible to return to peritoneal dialysis or if the peritoneal function is lost - transfer to hemodialysis followed by a second transplantation. The current level of development of renal replacement therapy allows us to predict several decades of active and fulfilling life. Nevertheless, chronic renal failure is considered a progressive disease and mortality among children receiving dialysis is 30-150 times higher than in the general population. At the present stage, life expectancy for a child who began to receive dialysis before the age of 14 is about 20 years (US data). That is why the diagnostic and therapeutic approach to chronic renal failure should be directed to primary prevention, early diagnosis and active treatment at all stages.

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