√лавна€  аталог болезней Ѕолезни почек и мочевых путей ’роническа€ почечна€ недостаточность
–едакци€ портала
03 марта 2014, 22:55 603 +2

’роническа€ почечна€ недостаточность 

√руппа заболеваний: болезни почек и мочевых путей
—межные болезни: остра€ почечна€ недостаточность
¬рач в каталоге: уролог
ѕораженный орган: почки
 

‘акторы риска

  • ƒиабет
  • Ќаследственна€ предрасположенность
  • јутоиммунные заболевани€
  • √ипертони€
  • ¬озраст старше 60 лет
  • ’ронические заболевани€ почек

ќписание

’роническа€ почечна€ недостаточность (от. англ. chronic kidney disease, сокр. ’Ѕѕ) - постепенно прогрессирующее расстройство гомеостаза организма, сопровождающеес€ снижением функции почек в течение 3 мес€цев и более. ƒл€ данного состо€ни€ характерна гибель нефронов (рабочих клеток почки) и замещение их соединительной тканью вследствие различных патологических процессов в организме. 

–анее хронической почечной недостаточностью называли медленно прогрессирующее нарушение выделительной функции почек, дл€щеес€ в течение мес€цев или лет, и определ€емое по снижению скорости клубочковой фильтрации ниже нормы, котора€ обычно косвенно определ€лась путЄм измерени€ содержани€ креатинина сыворотке крови.

„астота данного состо€ни€ колеблетс€ в пределах 100–600 человек на 1 000 000 взрослого населени€. «аболевание чаще всего развиваетс€ у престарелых людей.

 лассификаци€

—уществовало несколько различных классификаций ’ѕЌ; в частности, использовались классификации –атнер ћ.я. (по уровню креатинина – конечного продукта обмена белков), “ареева (по величине — ‘), урологов –€бова и  учинского (комплексна€). 

—овременна€ классификаци€ основана на двух показател€х - скорости клубочковой фильтрации (— ‘) и признаках почечного повреждени€ (протеинури€альбуминури€). ¬ зависимости от их сочетани€ выдел€ют п€ть стадий хронической болезни почек.

—тади€ќписание— ‘, мл/мин
1 ѕризнаки нефропатии, нормальна€ — ‘ > 90
ѕризнаки нефропатии, легкое снижение — ‘ 60 - 89
3ј  ”меренное снижение — ‘ 45 - 59
3Ѕ  ¬ыраженное снижение — ‘ 30 - 44
4   “€желое снижение — ‘ 15 - 29
5   “ерминальна€ хроническа€ почечна€ недостаточность < 15

—тадии 3-5 соответствуют определению хронической почечной недостаточности (снижение — ‘ 60 и менее мл/мин). —тади€ 5 соответствует терминальной хронической почечной недостаточности.

ѕричины

ќсновными причинами хронической почечной недостаточности €вл€ютс€:

  • первичное поражение клубочкового аппарата почек (хронический гломерулонефрит, гломерулосклероз); 
  • первичные поражени€ канальцев (хроническа€ гиперкальциеми€, врожденна€ оксалатеми€, хронические отравлени€ т€желыми металлами, такими как кадмий, свинец, ртуть и др.); 
  • вторичные поражени€ канальцев - хронический пиелонефрит
  • ещЄ одна причина хронической почечной недостаточности - двусторонние аномалии почек и мочеточников (гипоплази€ почек, губчата€ почка, поликистоз почек, нейромышечна€ дисплази€ мочеточников, последн€€ характерна дл€ детского возраста); 
  • хронический интерстициальный нефрит при передозировке фенацетина; 
  • обструктивные заболевани€ верхних (камни, опухоли, забрюшинный фиброз) и нижних (аномалии шейки мочевого пузыр€ и мочеиспускательного канала, стриктура уретры, мочекаменна€ болезнь, аденома и рак предстательной железы, рак мочевого пузыр€) мочевых путей с присоединением хронического пиелонефрита; 
  • системные коллагеновые заболевани€ (склеродерми€, волчанка, узелковый периартериит, ревматоидный артрит); 
  • заболевани€ почек обменного генеза (сахарный диабет, подагра с мочекислой нефропатией, первичный гиперпаратиреоидизм). 

 ак развиваетс€ болезнь

ƒл€ пациентов с хронической почечной недостаточностью характерно постепенное сморщивание и уменьшение размеров почек.  оличество почечных клубочков уменьшаетс€ с 2 млн. у здоровых людей до 200-400 тыс. Ќа первых порах здоровые нефроны берут на себ€ функцию пораженных, однако со временем компенсаторные возможности почек истощаютс€, продукты обмена не вывод€тс€ с мочой, а накапливаютс€ в организме, поврежда€ другие ткани и органы.

√ипертрофи€ оставшихс€ клубочков происходит в св€зи с их неспособностью к регенерации погибающих нефронов и необходимостью компенсировать функцию склерозированных нефронов. ¬ организме развиваютс€ фибропластические процессы с замещением нефронов соединительной тканью.

ѕовышенна€ нагрузка на функционирующие нефроны €вл€етс€ основным неиммунным механизмом прогрессировани€ хронической почечной недостаточности–езкое снижение массы действующих нефронов при хронической почечной недостаточности обусловливает развитие следующих основных патогенетических факторов:

  • Ќарушение выделительной функции почек и задержка в организме продуктов азотистого обмена - мочевины, креатинина, мочевой кислоты, индола и других. ¬озникает токсическое вли€ние этих веществ на ÷Ќ— и другие органы и ткани. ¬ насто€щее врем€ большое значение в качестве «уремических токсинов» придаетс€ таким продуктам белкового метаболизма, как гуанидин и его производные, полиамины, миоинозитол, а также вещества с молекул€рной массой от 300 до 5000 дальтон (так называемые «средние молекулы»). 
  • Ќарушение водного баланса имеет большое значение в развитии клиники хронической почечной недостаточности. ћеханизм этих нарушений включает анатомическое повреждение мозгового сло€ почки. ”целевшие нефроны функционируют в услови€х повышенной осмотической нагрузки и должны вывести в минуту значительно большее количество растворимых веществ, чем нормальные нефроны, дл€ чего им необходимо увеличить объем выводимой мочи. ѕоэтому уже на ранних стади€х хронической почечной недостаточности нарушаетс€ способность почек к концентрации мочи, развиваютс€ никтури€, полиури€. ѕостепенно снижаетс€ относительна€ плотность мочи, развиваютс€ изостенури€, а затем гипостенури€. ¬ полиурической фазе развиваютс€ симптомы дегидратации. ¬ дальнейшем тер€етс€ способность почек к разведению мочи, в терминальном периоде количество мочи резко уменьшаетс€, возможны клинические про€влени€ гипергидратации. 
  • Ќарушение электролитного баланса. ѕри хронической почечной недостаточности почки сохран€ют способность выдел€ть с мочой натрий в количестве, приблизительно равном поступившему, за счет адаптационных механизмов. ѕо мере прогрессировани€ заболевани€ механизмы адаптации истощаютс€, и может развитьс€ солевое истощение. ” многих больных в терминальной стадии наблюдаетс€ задержка натри€ в организме, что может стать важной причиной выраженной артериальной гипертензии, осложн€ющей течение заболевани€. ” большинства больных с хронической почечной недостаточностью почки длительное врем€ поддерживают нормальный калиевый баланс, а при прогрессировании нарушени€ калиевого гомеостаза про€вл€ютс€ развитием гиперкалиемии или реже - гипокалиемии. √ипокальциеми€ вызывает развивитие системного остеопороза, остеомал€ции, деформации костей, полинейропатии. Ќар€ду с гипокальциемией развиваетс€ выраженна€ фосфатеми€, что в свою очередь снижает всасывание кальци€ в кишечнике. 
  • Ќарушение кислотно-щелочного равновеси€. 
  • √ормональные нарушени€ у больных хронической почечной недостаточностью. ” многих больных нарушен углеводный обмен, что выражаетс€ в гипергликемии, нарушении толерантности к глюкозе, нередко в гиперинсулинемии, увеличении глюконеогенеза. ” больных с т€желой стадией заболевани€ развиваетс€ поражение репродуктивной системы - синдром уремического гипогонадизма. 
  • –азвитие анемии при развитии хронической почечной недостаточности усугубл€ет ее клинические про€влени€. јнеми€ обусловлена уменьшением продукции эритропоэтина, увеличением продукции ингибитора эритропоэза, функциональной неполноценностью костного мозга, усилением гемолиза эритроцитов, вли€нием «уремических токсинов», нарушением всасывани€ железа и кровопотерей в св€зи с нарушением при хронической почечной недостаточности функции тромбоцитов. 
  • Ќарушение функции почечной прессорно-депрессорной системы - повышение продукции ренина и понижение - простагландинов, снижающих артериальное давление, что способствует развитию артериальной гипертонии. 

—имптомы

¬ зависимости от симптомов различают 4 стадии хронической почечной недостаточности:

  1. ѕолиурическа€ (стади€ компенсации, латентна€, доазотемическа€) - клинические про€влени€, св€занные с основным заболеванием, а также возможна легка€ утомл€емость и сухость во рту.
  2. —тади€ клинических про€влений (азотемическа€, олигоанурическа€) - по€вление интоксикации: анорекси€, неврологические нарушени€ (головна€ боль, апати€, снижение зрени€, бессонница), боли в кост€х и суставах, зуд. ѕо€вл€ютс€ диспептические нарушени€ - диаре€, рвота. —о стороны сердечно-сосудистой системы - тахикарди€, аритми€.
  3. —тади€ декомпенсации (интермиттирующа€) - присоедин€ютс€ стоматиты, гингивиты, плевриты, перикардиты, отЄк лЄгких, нарушаетс€ электролитный и кислотно-щелочной баланс, возникают жалобы на общую слабость, повышенную утомл€емость, снижение или отсутствие аппетита, жажду; периодически, в св€зи с обострением основного заболевани€ состо€ние больных ухудшаетс€, а после лечени€ отмечаетс€ положительна€ динамика.
  4. “ерминальна€ (уремическа€, анурическа€) стади€. »сход обычно летальный, единственный выход в этой ситуации радикальна€ пересадка почки. “акже эту стадию можно отсрочить пожизненным гемодиализом.

—имптомы почечной недостаточности в латентной стадии

Ќа первой стадии почечной недостаточности клиника зависит от заболевани€ - будь то отеки, гипертензи€ или боли в по€снице. „асто, например, при поликистозе или гломерулонефрите с изолированным мочевым синдромом, человек вообще не подозревает о своей проблеме.

  • Ќа этом этапе могут по€вл€тьс€ жалобы на бессонницу, утомл€емость, снижение аппетита. ∆алобы не слишком-то специфические, и без серьезного обследовани€ они вр€д ли помогут поставить диагноз.
  • ј вот по€вление более частого и обильного мочеиспускани€, особенно в ночные часы настораживает - это может быть признаком снижени€ способности почки концентрировать мочу.
  • √ибель части клубочков заставл€ет оставшиес€ работать с многократной перегрузкой, в результате чего жидкость не всасываетс€ в канальцах, и плотность мочи приближаетс€ к плотности плазмы крови. ¬ норме утренн€€ моча более концентрированна€, и если при повторном исследовании в общем анализе мочи удельный вес менее 1018, это повод сдать анализ по «имницкому. ѕри этом исследовании собираетс€ вс€ моча за сутки трехчасовыми порци€ми, и если ни в одной из них плотность не достигает 1018, то можно говорить о первых признаках почечной недостаточности. ≈сли во всех порци€х этот показатель равен 1010, значит, нарушени€ зашли далеко: плотность мочи равна по плотности плазме крови, реабсорбци€ жидкости практически прекратилась.

—имптомы почечной недостаточности в азотемической стадии

Ќа следующей стадии компенсаторные способности почек исчерпываютс€, они не способны вывести все конечные продукты обмена белка и пуриновых оснований, и при биохимическом анализе крови вы€вл€етс€ повышенный уровень шлаков - мочевина, креатинин. »менно концентраци€ креатинина в обычной клинической практике становитс€ индексом скорости клубочковой фильтрации (— ‘).

—нижение скорости клубочковой фильтрации до 60-89мл/мин - это почечна€ недостаточность легкой степени. Ќа этой стадии еще нет анемии, нет электролитных сдвигов, нет гипертензии (если она не €вл€етс€ про€влением исходного заболевани€), беспокоит лишь общее недомогание, иногда жажда. ќднако уже на этом этапе при целенаправленном обследовании можно вы€вить снижение уровн€ витамина ƒ и повышение паратгормона, хот€ до остеопороза ещЄ далеко. Ќа этой стадии ещЄ возможно обратное развитие симптомов.

≈сли усили€, направленные на лечение исходной болезни и защиту остаточной функции почек не принос€т успеха, то почечна€ недостаточность продолжает нарастать, — ‘ снижаетс€ до 30-59 мл/мин. Ёто треть€ стади€ ’Ѕѕ (хронической болезни почек), она уже необратима. Ќа этом этапе по€вл€ютс€ симптомы, несомненно свидетельствующие о снижении функций почки:

  • ѕовышаетс€ артериальное давление вследствие снижени€ синтеза в почке ренина и почечных простагландинов, по€вл€ютс€ головные боли, боли в области сердца.
  • Ќесвойственную ему работу по выведению шлаков отчасти берет на себ€ кишечник, что про€вл€етс€ неустойчивым стулом, тошнотой, снижением аппетита. ћожет снижатьс€ вес, тер€тьс€ мышечна€ масса.
  • ѕо€вл€етс€ анеми€ - почка вырабатывает недостаточно эритропоэтина.
  • —нижаетс€ уровень кальци€ в крови в результате нехватки активной формы витамина ƒ. ѕо€вл€етс€ мышечна€ слабость, онемение кистей и стоп, а также области вокруг рта. ћогут быть психические расстройства - как депресси€, так и возбуждение.

—имптомы почечной недостаточности в интермиттирующей стадии

ѕри т€желой степени почечной недостаточности (’Ѕѕ 4, — ‘ 15-29мл/мин)

  • к гипертензии присоедин€ютс€ нарушени€ липидного обмана, повышаетс€ уровень триглицеридов, холестерина. Ќа этом этапе очень высок риск сосудистых и мозговых катастроф.
  • ¬ крови повышаетс€ уровень фосфора, могут по€витьс€ кальцификаты - отложение фосфорно-кальциевых солей в ткан€х. –азвиваетс€ остеопороз, беспоко€т боли в кост€х и суставах.
  • ѕомимо шлаков, почки отвечают за выведение пуриновых оснований, по мере их накоплени€ развиваетс€ вторична€ подагра, могут развитьс€ типичные острые приступы суставных болей.
  • ѕо€вл€етс€ тенденци€ к повышению уровн€ кали€, котора€, особенно на фоне развивающегос€ ацидоза, может провоцировать нарушени€ сердечного ритма: экстрасистолию, мерцательна€ аритмию. ѕо мере нарастани€ уровн€ кали€ урежаетс€ сердцебиение, а на Ё √ могут по€витьс€ «инфарктоподобные» изменени€.
  • ѕо€вл€етс€ непри€тный вкус во рту, запах аммиака изо рта. ѕод действием уремических токсинов увеличиваютс€ слюнные железы, лицо становитс€ одутловатым, как при паротите.

—имптомы почечной недостаточности в терминальной стадии

’Ѕѕ 5 степени, уреми€, — ‘ менее 15мл/мин. —обственно, на этом этапе больной должен получать заместительное лечение - гемодиализ или перитонеальный диализ.

  • ѕочки практически перестают производить мочу, диурез снижаетс€ вплоть до анурии, по€вл€ютс€ и нарастают отеки, особенно опасен отек легких.
  •  ожа желтушно-сера€, часто - со следами расчесов (по€вл€етс€ кожный зуд).
  • ”ремические токсины вызывают склонность к повышенной кровоточивости, легко образуютс€ син€ки, кровоточат десна, идет кровь из носа. Ќередки желудочно-кишечные кровотечени€ - черный стул, рвота в виде кофейной гущи. Ёто усугубл€ет имеющуюс€ анемию.
  • Ќа фоне электролитных сдвигов возникают неврологические изменени€: периферические - вплоть до параличей, и центральные - тревожно-депрессивные или маниакальные состо€ни€.
  • √ипертензи€ не поддаетс€ лечению, выраженные нарушени€ сердечного ритма и проводимости, формируетс€ застойна€ сердечна€ недостаточность, может развитьс€ уремический перикардит.
  • Ќа фоне ацидоза отмечаетс€ шумное аритмичное дыхание, снижение иммунитета и застойные €влени€ в легких могут спровоцировать пневмонию.
  • “ошнота, рвота, жидкий стул - про€влени€ уремического гастроэнтероколита.

Ѕез гемодиализа продолжительность жизни таких пациентов исчисл€етс€ недел€ми, если не дн€ми, поэтому больные должны попадать в поле зрени€ нефролога значительно раньше.

“аким образом, специфические симптомы, которые позвол€т поставить диагноз почечной недостаточности, развиваютс€ достаточно поздно. Ќаиболее эффективное лечение возможно на 1-2 стадии ’Ѕѕ, когда жалобы практически отсутствуют. ј вот минимальные обследовани€ - анализы мочи, общий и клинический анализы крови, дадут достаточно полную информацию. ѕоэтому так важно дл€ пациентов из групп риска регул€рно обследоватьс€, а не просто показыватьс€ врачу.

ќписание синдромов при ’ѕЌ

ƒл€ ’ѕЌ характерно медленно прогрессирующее течение с периодами ухудшени€ и улучшени€, нередко с многолетним периодом относительной компенсации. ѕри прогрессировании ’ѕЌ клиническа€ картина характеризуетс€ р€дом синдромов:

  • јстенический синдром 

Ѕольных беспоко€т следующие симптомы хронической почечной недостаточности: слабость, быстра€ утомл€емость, в€лость, нередко выраженна€ апати€, значительное ограничение, а в далеко зашедших случа€х и полна€ утрата трудоспособности.

  • ƒистрофический синдром 

Ѕольные жалуютс€ на сухость и мучительный зуд кожи, св€занный с выделением через кожу кристаллов мочевины. Ѕольные отмечают также выраженную слабость, значительное похудание. Ћицо одутловатое, бледно-серого цвета. ћышцы атрофичны, сила и тонус их резко снижены. ’арактерно похудание, возможна насто€ща€ кахекси€. 

  • ∆елудочно-кишечный синдром 

—имптомы хронической почечной недостаточности при желудочно-кишечном синдроме следующие: сухость и горечь во рту, отсутствие аппетита, тошнота и рвота, т€жесть и боли в подложечной области после еды, поносы, возможно повышение кислотности желудочного сока, а в дальнейшем – обычно снижение; впоздних стади€х ’ѕЌ могут быть желудочно-кишечные кровотечени€, стоматит, паротит, выраженный энтероколит, нарушение функции печени. ѕриблизительно у половины больных отмечаетс€ жажда, причем она не провоцируетс€ приемом мочегонных средств. ” некоторых больных бывает мучительна€ икота. 

  • —ердечно-сосудистый синдром 

ѕрежде всего практически у 100% больных вы€вл€етс€ артериальна€ гипертензи€. —ледстви€ми артериальной гипертензии €вл€ютс€: головные боли, боли в области сердца, снижение зрени€, гипертрофи€ и дилатаци€ левого желудочка.

” 70% больных с ’ѕЌ имеетс€ поражение миокарда по типу миокардиодистрофии. ѕоражение миокарда у больных с ’ѕЌ про€вл€етс€ бол€ми в области сердца посто€нного характера, одышкой, сердцебиением, перебо€ми в области сердца, глухостью тонов, в т€желых случа€х – левожелудочковой недостаточностью.

¬ терминальной стадии ’ѕЌ развиваетс€ перикардит. ќн про€вл€етс€ интенсивными посто€нными бол€ми в области сердца, усиливающимис€ при кашле, глубоком вдохе; одышкой, набуханием шейных вен, правожелудочковой недостаточностью; шумом трени€ перикарда; конкордантным подъемом интервала ST с одновременной его вогнутостью или диффузным снижением вольтажа зубцов Ё √. 

  • ѕлевропульмональный синдром 

ѕоражение легких при ’ѕЌ может про€витьс€ в виде следующих форм: уремический пневмонит, нефрогенный отек легких, острые пневмонии.  линически уремический перикардит про€вл€етс€ сухим кашлем, коробочным оттенком перкуторного звука, жестким или ослабленным везикул€рным дыханием, небольшим количеством сухих или влажных хрипов, усилением легочного рисунка на рентгенограмме.

 линически нефрогенный отек легких может протекать латентно или про€вл€тьс€ одышкой или приступами удушь€, кашлем с отделением мокроты, иногда пенистой, розовой. Ѕольной занимает вынужденное положение, покрыт холодным потом, тоны сердца глухие; при аускультации определ€етс€ большое количество влажных хрипов, преимущественно в нижних отделах.

ƒл€ своевременной диагностики нефрогенного отека легких необходимы ежедневный контроль массы тела, а также рентгенографи€ легких. Ѕольные с ’ѕЌ в большей степени предрасположены к острым пневмони€м, которые, как правило, дают типичную клиническую картину. ” р€да больных с ’ѕЌ может развитьс€ уремический плеврит. ‘иброзный плеврит про€вл€етс€ интенсивными бол€ми в грудной клетке, усиливающимис€ при дыхании, кашле, шумом трени€ плевры. Ёкссудативный плеврит характеризуетс€ выращенной одышкой, цианозом, резким ослаблением везикул€рного дыхани€ на стороне поражени€ вплоть до его исчезновени€, по€влением тупого звука при перкуссии легких. 

  •  остно-суставной синдром чрезвычайно характерен дл€ ’ѕЌ. 

ѕоражение скелета и м€гких тканей, развивающеес€ вследствие нарушенного обмена у больных ’ѕЌ, называетс€ еще почечной остеодистрофией. ¬ насто€щее врем€ почечные дистрофии дел€т на две большие подгруппы: почечна€ фиброзна€ остеодистрофи€ (или фиброзный остеит, вторичный гиперпаратиреоз) и почечна€ остеомал€ци€. 

  • —индром эндокринных дисфункций 

√ормональные дисфункции, как правило, характерны дл€ выраженной стадии ’ѕЌ. »зменени€ уровней гормонов в плазме крови больных представлены в “аблице "“ипичные изменени€ гормонов плазмы при ’ѕЌ" (—. ». –€бов, 1982). 

  • јнемический синдром 

¬ыраженность анемии коррелирует с уровнем креатинина, мочевины, клубочковой фильтрации. ¬следствие анемии развиваютс€ дистрофические изменени€ в органах и ткан€х, снижаетс€ толерантность к физическим нагрузкам. 

  • Ќарушение кислотно-щелочного равновеси€ 

ѕо механизму возникновени€ различают метаболический ацидоз гломерул€рного и канальцевого происхождени€. √ломерул€рный ацидоз развиваетс€ при заболевани€х почек с преимущественным поражением клубочков, в первую очередь при хронических нефритах. ћетаболический ацидоз в этих случа€х развиваетс€ в сравнительно поздних стади€х заболевани€.  анальцевый ацидоз развиваетс€ при заболевани€х, поражающих преимущественно канальцы почек,– хроническом пиелонефрите, интерстициальном нефрите и др.  анальцевый ацидоз более выражен и более устойчив, чем клубочковый. 

  • Ёлектролитные нарушени€ 

ѕри выраженных стади€х ’ѕЌ, особенно в терминальной стадии, наблюдаетс€ такой симптом хронической почечной недостаточности, как гиперкалиеми€.  онцентраци€ натри€ в крови мен€етс€ несущественно, хот€ в целом имеетс€ тенденци€ к его снижению, особенно при неоправданно строгом соблюдении бессолевой диеты. ƒинамика концентрации хлора несущественна. ѕри неукротимой рвоте и поносе может по€витьс€ гипохлореми€, что способствует слабости, снижению аппетита. ¬ терминальной стадии часто отмечаетс€ тенденци€ к гиперхлоремии.  онцентраци€ кальци€ в крови всегда отчетливо снижаетс€.  онцентраци€ магни€ в крови больного, как правило, несколько повышена.  онцентраци€ фосфора в крови больного также имеет тенденцию к повышению. 

  • Ќарушени€ водного баланса 

Ќарушени€ гомеостаза жидкостей тела представл€ют собой одно из наиболее частых и ранних про€влений ’ѕЌ и выражаютс€ в полиурии, никтурии, гипоизостенурии. 

ƒиагностика

ƒиагноз став€т на основании данных анамнеза о хроническом заболевании почек, характерных симптомов уремии, лабораторных данных об азотемии и других типичных расстройствах гомеостаза. 

Ќаиболее надежными показател€ми, отражающими де€тельность почек и выраженность почечной недостаточности, €вл€ютс€ креатининеми€ в сопоставлении с креатининурией и клубочковой фильтрацией. Ќекоторые специалисты по-прежнему предлагают определ€ть при ’ѕЌ остаточный азот крови. ¬ остаточном азоте наибольшее значение имеет мочевина. Ќарастание концентрации в крови характерно дл€ ’ѕЌ и отражает т€желое нарушение функции почек. ѕри далеко зашедших случа€х почечной недостаточности возможно повышение содержани€ мочевой кислоты, что может быть причиной по€влени€ симптомов подагры.

Ћабораторна€ диагностика вы€вл€ет:

  • общий анализ крови при лечении хронической почечной недостаточности характеризуетс€ прогрессирующей гипорегенераторной анемией, лейкоцитозом, тромбоцитопенией;
  •  ‘ (клубочкова€ фильтраци€) менее 20 мл/мин на 1,73 м² (проба –еберга);
  • креатинин сыворотки более 0,132 ммоль/л;
  • мочевина более 8,3 ммоль/л.

ѕри гибели менее 50 % нефронов ’ѕЌ можно вы€вить только при функциональной нагрузке.

ѕри компьютерной томографии и ультразвуковом исследовании, как правило, определ€етс€ значительное уменьшение почек в размерах и рубцевание почечной ткани. Ёто можно видеть и на обзорной рентгенографии почек.

Ћечение

ѕри ’ѕЌ лечение больных комплексное. ¬ первую очередь устран€ют первопричину, вызывающую почечную недостаточность. Ћечение включает в себ€ консервативную терапию (диету, дезинтоксикационную терапию), а также диализ и трансплантацию почки.

ƒиета при хронической почечной недостаточности

ўад€щий режим с ограничением физической нагрузки благопри€тно вли€ет на результаты лечени€. »з диетических меропри€тий при лечении хронической почечной недостаточности рекомендуютс€:

  • малобелкова€ пища (от 60 до 20 г в сутки); 
  • обеспечение энергетической потребности приемом пищи, богатой жирами (сливочное масло до 100 г в сутки, свиное сало) и углеводами (картофель); 
  • прием витаминов и микроэлементов; 
  • контроль адекватного поступлени€ натри€: значительное ограничение при гипернатриемии и нормальное потребление дл€ обеспечени€ наилучших условий фильтрации при отсутствии гипертонии; 
  • потребление достаточного количества жидкости (1500-2000 мл) при контроле за суточным диурезом. 

ƒополнительное введение жидкости

ѕри сохраненной водовыделительной функции почек целесообразно обильное введение жидкости, а дл€ алкализации плазмы и возмещени€ потерь натри€ следует вводить 5%-ный раствор натри€ гидрокарбоната (до 500 мл), 5-20%-ный раствор глюкозы (300-500 мл), при упорной рвоте - 3%-ный раствор натри€ хлорида (до 200-300 мл).

ѕри отеках, обусловленных снижением осмотического давлени€ плазмы, примен€ют 20%-ный раствор глюкозы с инсулином (на каждые 4 г сухой глюкозы 1 ≈ƒ инсулина). ѕри гипокальциемии примен€ют кальци€ глюконат (10%-ный раствор до 50 мл в сутки внутримышечно).

ћедикаментозное лечение хронической почечной недостаточности

“ерапи€ строго индивидуальна в каждом случае, и подбираетс€ лечащем врачем. ƒл€ устранени€ симптомов используют следующие препараты.

— целью снижени€ катаболических процессов назначают анаболические гормоны из расчета 100 мг в сутки: 5%-ный раствор тестостерона пропионата, метандростенолон по 0,005 г 3 раза в день, метиландростендиол в таблетках по 0,025 г 4 раза в день. Ћечение провод€т в течение 20 дней, затем после 10-дневного перерыва - повторный 20-дневный курс.

ƒл€ улучшени€ почечной микроциркул€ции следует длительно примен€ть трентал, троксевазин, компламин, курантил.

ƒл€ стимул€ции диуреза назначают 10-20%-ный раствор глюкозы с инсулином и маннитом по 500 мл внутривенно капельно. ¬озможно также применение диуретиков из группы фуросемида. ѕри активации нефротоксического синдрома необходимо длительное применение кортикостероидов.

ѕри высокой гиперазотемии полезно промывание желудка и кишечника 2%-ным раствором натри€ гидрокарбоната, которое способствует удалению азотистых шлаков. Ёту процедуру провод€т натощак, перед едой, 1 раз в день.

ћетоды консервативной терапии ’ѕЌ с успехом примен€ютс€ у больных с умеренными про€влени€ми уремической интоксикации при отчетливо сохраненной водовыделительной функции почек и гиперазотемии, не превышающей 22 моль/л мочевины. ¬ поздних стади€х ’ѕЌ консервативна€ терапи€, как правило, малоэффективна, в св€зи, с чем возникает необходимость в применении очищени€ крови методами диализа.

¬ насто€щее врем€ дл€ лечени€ больных с терминальной стадией ’ѕЌ все чаще используют посто€нный перитонеальный диализ. ћеханизм его действи€ основан на том, что брюшина играет роль диализной мембраны. Ёффективность перитонеального диализа не ниже гемодиализа, а по некоторым показател€м даже выше.

√емодиализ при хронической почечной недостаточности

ƒл€ лечени€ больных с ’ѕЌ в насто€щее врем€ с большим успехом примен€етс€ гемодиализ с помощью аппарата «искусственна€ почка», который периодически подключают к больному. —уть метода сводитс€ к аппаратной очистке крови, при помощи фильтрации. јппарат отфильтровывает из крови продукты распада и излишки воды. ќчищенна€ кровь возвращаетс€ в организм.

—еанс гемодиализа обычно продолжаетс€ 5-6 ч, его повтор€ют 2-3 раза в неделю. ѕоказани€ к более частому проведению диализа возникают при быстром усилении уремической интоксикации.

ќсложнени€ гемодиализа св€заны с почечной недостаточностью и с многократным применением диализа.   ним относитс€ прогрессирующа€ анеми€. ¬ результате высокого давлени€ могут возникнуть нарушени€ мозгового кровообращени€, сердечно-сосудиста€ недостаточность. ќсобенно опасны выпотной и сухой перикардит. „асто бывают инфекционные осложнени€. ѕрогрессирующа€ нейропати€ характерна дл€ ’ѕЌ и может прогрессировать в ходе многочисленного гемодиализа.

’ирургическое лечение

ќперативное лечение хронической почечной недостаточности заключаетс€ в проведении трансплантации почки. ѕоказанием к пересадке почки, так же как и дл€ гемодиализа, €вл€етс€ терминальна€ стади€ ’ѕЌ, развивша€с€ на почве хронического пиелонефрита, хронического гломерулонефрита, коралловых камней почек, поликистоза почек, гидронефроза, вторичных аномалий развити€ и некоторых системных заболеваний.

ѕротивопоказани€ми следует считать крайне т€желое состо€ние больного, €звенную болезнь, психические заболевани€, эндокринные расстройства. 

ѕрофилактика

  профилактическим методам хронической почечной недостаточности относ€тс€: здоровый образ жизни и своевременное вы€вление, а так же грамотное и профессиональное лечение системных заболеваний.

 
–едакци€ портала
03 марта 2014, 22:55
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