Everyone Enjoys Kidney Health, And Whole-process Management Is Essential

Chronic kidney disease (CKD) is a common chronic disease that cannot be cured so far and has a high disability and mortality rate. It is predicted that by 2040, CKD will become the fifth leading cause of death in the world, and about 10% of adults worldwide suffer from CKD. According to the latest Sixth China Chronic Disease and Risk Factor Surveillance Report, the prevalence of adult CKD in China is about 8.2%, which is lower than the 10.8% prevalence announced in 2009, but there are still About 82 million adults suffer from CKD, and the awareness rate is only 10%. Improving public awareness of CKD is of great significance to the prevention and control of CKD.

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Strengthen the whole process management to reduce the disability and fatality rate of nephropathy

As we all know, uremia is the end-stage manifestation of renal failure, requiring dialysis or kidney transplantation to maintain life. Before nausea, vomiting, edema, anemia, chest tightness, and other uremia symptoms appear, CKD patients may have no obvious symptoms. Early monitoring and intervention are crucial to protect renal function and delay entering dialysis. Therefore, we call for strengthening the whole-process management of CKD high-risk groups and patients to reduce the morbidity and mortality of kidney disease.

Regular screening is an important means to discover CKD

Similar to the low awareness of CKD is the lack of screening for CKD. In January 2022, the National Health Commission and the State Administration of Traditional Chinese Medicine organized the formulation of a technical plan for the hierarchical diagnosis and treatment of seven major chronic diseases including CKD in county areas, which clarified the monitoring frequency of healthy people, CKD high-risk groups and CKD patients (for example, for the general population, It is recommended to test urine routine and serum creatinine once a year; for CKD high-risk groups, urine routine, and serum creatinine should be tested at least once a year; it is recommended that CKD patients should have estimated glomerular filtration rate and urine albumin tested at least once every six months ).

The management and detection of CKD high-risk groups and CKD patients (especially early and stable patients) should be mainly carried out in communities and primary medical institutions. However, the main role of primary medical institutions in CKD follow-up in China has not yet been fully exerted.

A multi-pronged approach to prevent and treat CKD progress

Lifestyle adjustments. Obesity and smoking are risk factors for CKD. Therefore, it is recommended that CKD patients participate in tolerable physical exercise (maintaining a body mass index between 18.5 and 24) under the guidance of a physician and quit smoking.

nutritional therapy. The nutritional therapy of CKD patients is very important, and the nutritional status directly affects the prognosis of patients. The latest guidelines suggest that CKD patients at each stage should tailor their nutritional therapy plan according to their individual needs, nutritional status, and concurrent diseases. Nutritional therapy should be carried out by professionals (nutritionists or doctors, nurses, and other medical workers with the same ability) based on individualized assessment. It is necessary to ensure that patients have sufficient energy and appropriate protein intake to avoid malnutrition and not increase the burden on the kidneys. At present, Chinese doctors and patients do not have enough awareness of CKD nutrition therapy, and there is a lack of professionals.

Control proteinuria, hypertension, hyperglycemia, hyperlipidemia, and hyperuricemia. These factors are all risk factors for accelerating the progression of CKD and are also related to the occurrence of cardiovascular events. Therefore, it is necessary to evaluate the above indicators for CKD patients, and to carry out drug treatment under the guidance of doctors, to achieve the control goals recommended by the guidelines. When selecting drugs, eligible patients are recommended to use drugs that have a protective effect on the kidneys, such as angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) antihypertensive drugs, sodium- Glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonist. Finerenone is a third-generation mineralocorticoid receptor antagonist, which has good renal and cardiac dual protective effects on type 2 diabetes-related CKD. It is recommended that the estimated glomerular filtration rate ≥ 25 ml/(min·1.73㎡), normal blood potassium, and the presence of albuminuria (white urine) after using the maximum tolerable dose of the renin-angiotensin system (RAS) inhibitors Finerenone is used in patients with type 2 diabetes with a protein/creatinine ratio ≥30 mg/g. The drug has been included in the 2022 National Medical Insurance Drug List.

Pay attention to drug safety. Some drugs are excreted by the kidneys, and the dosage should be adjusted according to the level of glomerular filtration rate to avoid the occurrence of adverse drug reactions. Common nephrotoxic drugs include some antibiotics (such as gentamicin, vancomycin, etc.), non-steroidal anti-inflammatory drugs, tumor chemotherapy drugs (such as cisplatin), contrast media, cyclosporine, and some traditional Chinese medicines. Therefore, CKD patients should use non-prescription drugs or protein nutrition products under the guidance of physicians or pharmacists. In addition, common kidney damage poisons include heavy metals (such as lead, mercury, cadmium), organic solvents (such as tetrachloromethane, xylene, etc.), pesticides, and biological toxins (such as snake venom, bee venom, and poisonous mushrooms). Contact should be avoided.

Complications of CKD and related prevention methods

CKD (especially advanced to the late stage) has many complications and complicated conditions, which bring great pain to patients. Prevention and treatment of CKD complications are of great significance for delaying disease progression, improving patients' quality of life, and improving prognosis. Anemia, cardiovascular disease, CKD abnormal mineral and bone metabolism, acidosis, hyperkalemia, infection, etc. are common complications of CKD. Evaluation, diagnosis, and treatment of the above diseases require specialist physicians.

Erythropoiesis-stimulating agents and oral iron are commonly used drugs for the treatment of renal anemia, and hypoxia-inducible factor prolyl hydroxylase inhibitors (such as roxadustat) as new oral drugs for the treatment of renal anemia have become more and more popular. widely used clinically. It is recommended that the starting time for roxadustat in the treatment of renal anemia is when the hemoglobin is <100 g/L, and the target hemoglobin is maintained at ≥110 g/L but not more than 130 g/L. The initial dose is 100 mg (body weight <60 kg) or 120 mg (body weight ≥60 kg) for dialysis patients, 70 mg (body weight <60 kg) or 100 mg (body weight ≥60 kg) for non-dialysis patients, 3 times a week, oral administration.

Cardiovascular events are the leading cause of death in CKD patients. Angiotensin receptor neprilysin inhibitors act on the RAS system and neprilysin at the same time. In addition to reducing blood pressure, they can also improve cardiac structure and reduce the risk of cardiovascular death and heart failure. For heart failure patients with CKD and reduced ejection fraction who can tolerate ARB/ACEI therapy, angiotensin receptor neprilysin inhibitors are recommended instead of ARB/ACEI.

Disorders of mineral and bone metabolism can appear in the early stage of CKD and progress with the decline of renal function. The detection frequencies of serum phosphorus, calcium, alkaline phosphatase, intact parathyroid hormone, and 25-hydroxyvitamin D were related to the CKD stage. Phosphorus reduction can follow the 3D principles: Drug (rational use of phosphorus binders), Diet (limitation of phosphorus intake), and Dialysis (adequate dialysis). Drugs that lower whole parathyroid hormone mainly includes active vitamin D and its analogs and calcimimetics.

Hyperkalemia has the risk of causing fatal arrhythmia and cardiac arrest, and once hyperkalemia occurs in CKD patients, it is easy to recur, which is one of the reasons why patients enter dialysis, so long-term management of serum potassium needs to be strengthened. Patients with hyperkalemia should have a low-potassium diet, adjust the dosage of RAS inhibitors, and take oral potassium-lowering agents, including calcium polystyrene sulfonate and sodium zirconium cyclosilicate. According to the patient's residual renal function and urine output, the use of potassium-sparing diuretics should be considered appropriate.

The risk of infection in CKD patients is 3 to 4 times that of normal people. Prevention and treatment of infection can effectively reduce the risk of CKD renal function deterioration and delay the progression of the disease. Usually should pay attention to the prevention of the respiratory tract and urinary tract and other parts of the infection. Vaccines are also recommended to prevent infection. Annual influenza vaccination is recommended for all adults with CKD unless contraindicated. Inoculation of polyvalent pneumonia vaccine and hepatitis B vaccine can also benefit some CKD patients, but it should be noted that the immune status of the patients should be fully evaluated before using live vaccines, and the relevant vaccination documents of government agencies should be followed.

Treatment options for patients with end-stage renal disease

Renal replacement therapy modalities include dialysis (hemodialysis, peritoneal dialysis) and kidney transplantation. Due to the shortage of kidney donors, most patients with the end-stage renal disease currently require dialysis to maintain their lives. Since most patients with dialysis and kidney transplantation need to go to the outpatient clinic for follow-up regularly, the management of patients is more closely, and standardized dialysis treatment and long-term follow-up should be emphasized.

In the recent COVID-19 pandemic, CKD patients, especially children, the elderly, and patients with end-stage renal disease, are undoubtedly the groups that need to focus on due to their low immunity and high dependence on medical resources. Aiming at the problems of epidemic prevention and control and dialysis treatment of hemodialysis patients, the National Nephrology Professional Medical Quality Management and Control Center released the "Expert Consensus on Hemodialysis Quality Control During the Prevention and Control of Novel Coronavirus Pneumonia Epidemic" in July 2022 to ensure the blood life safety of dialysis patients. Peritoneal dialysis patients can undergo dialysis treatment at home, which undoubtedly has unique advantages during the epidemic and can be given priority.

summary

In short, CKD is a common chronic disease that accompanies patients throughout their lives. Strengthening the standardized management of patients is crucial to improving their quality of life and reducing disability and mortality rates. In the management process of CKD patients, in addition to the need to give full play to the role of grassroots medical institutions, the value of nurses, nutritionists, pharmacists, endocrinologists, cardiologists, and other department doctors is also very important. In addition, new chronic disease management models such as the Internet + medical model and the medical association (community) model also provide new possibilities for CKD management.