With the increase in the incidence of hypertension, atherosclerosis, diabetes and other diseases, as well as population aging, end stage renal disease (end stage renal disease, ESRD) incidence was significantly increased. According to the incomplete data, there are about 150 to 200 cases of ESRD patients per million population in the country. The so-called "ESRD integrated treatment" refers to the timely and early diagnosis of ESRD, timely initiation of renal replacement therapy, protection of residual renal function, delay the progression of the disease, prevention and treatment of its complications, while education and guidance on disease knowledge, so that ESRD Patients get the best quality of life and restore their ability to work as much as possible.
1. timely and early diagnosis
Knowledge of kidney disease, once found to have kidney disease progress, patients should be referred to the kidney specialist treatment. For patients with chronic kidney disease, given early treatment, education, guidance, to delay the development of chronic renal failure; when the development to the ESRD stage, timely treatment of renal replacement. At present, the prevalence of renal replacement therapy in China is prevalent, so that the incidence of various complications (such as infection, heart failure, malnutrition, etc.) in ESRD patients is increased, the hospitalization rate increases, the total medical expenses increases, the survival rate and life of patients Quality is not guaranteed.
2. Improve the preparation of renal replacement therapy
Patients and their families, so that they understand the necessity of renal replacement therapy and the advantages and disadvantages of various therapies, from the psychological, physiologically prepared and accepted alternative therapy. The establishment of dialysis pathway, the preparation of peritoneal dialysis, it is best in the 2 weeks after the operation of dialysis; preparation of hemodialysis, the best in the establishment of arteriovenous fistula 2 months after the start of dialysis.
3. timely start renal replacement therapy
On the beginning of renal replacement therapy, foreign scholars put forward the "timely, more healthy start" concept, that is, patients with significant symptoms of uremia before the start of renal replacement therapy, the purpose is to improve the patient's health, reduce the cause of uremia complication.
4. Selection of renal replacement therapy
At present, kidney replacement therapy has dialysis therapy (hemodialysis, peritoneal dialysis and other blood purification therapy) and kidney transplantation.
Peritoneal dialysis
Using the patient's peritoneum as a semipermeable membrane, with the plasma and peritoneal dialysis solution between the solute concentration gradient and osmotic gradient to remove toxins, correct water, electrolyte metabolism and acid-base balance disorders. Relative hemodialysis, ESRD patients with early peritoneal dialysis can effectively remove the molecular substances, to protect the residual renal function, to maintain cardiovascular function and stability. Therefore, ESRD patients with dialysis should be the first choice for peritoneal dialysis. At the first 2 years of dialysis treatment, the survival rate of patients treated with peritoneal dialysis was higher than that of hemodialysis patients. However, it is worth noting that the survival rate of peritoneal dialysis treatment is still lower than hemodialysis, peritoneal dialysis in the withdrawal of the reasons, peritonitis is the most important factor, followed by dialysis is not sufficient (including solute clearance is not enough and water scavenging) The In recent years, the study of peritoneal dialysis is how to improve the biocompatibility of dialysate and improve the efficiency of dialysis.
Hemodialysis
With the combination of modern science and technology and medical treatment, hemodialysis device gradually improved, such as dialysis membrane biocompatibility and the use of high-throughput filter, making the dialysis effect is getting better. 3 times a week, each 4 to 5 hours hemodialysis treatment has a short and efficient characteristics, can be accumulated in the body of most of the small molecule toxins as well as part of the macromolecular toxins excreted. Currently hemodialysis model hemodialysis, hemodialysis filtration, continuous hemodialysis filtration and other ways for patients with different disease options. But hemodialysis there are some problems, such as: ① even the most effective hemodialysis treatment can only be equivalent to 10% to 20% of the normal kidneys on the removal of small molecules solute efficiency, and the removal of large molecular weight solute is even more (2) dialysis patients with hepatitis B virus, hepatitis C virus infection infection rate is higher; ④ the establishment of vascular access to the hemodynamics and the heart Function of the larger impact.
Kidney transplant
For ESRD patients, kidney transplantation is the best choice for a healthy and viable life. Successful renal transplant recipients are significantly superior to dialysis patients in terms of satisfaction with life, physical and emotional comfort, and ability to re-work, and kidney transplantation can correct or improve the combination of uremia that can not be completely reversed by dialysis Such as anemia, peripheral neuropathy, autonomic neuropathy and sexual dysfunction. At present, kidney transplantation surgery technology has been basically mature, transplantation immunology has also made great progress. The clinical application of various new immunosuppressive drugs, so that kidney transplant patients kidney 1 year and 5 years survival rates were 90% and 70%. Such as cyclosporine or tacrolimus (FK506) plus mycophenolate methyl ester (mycophenolate mofetil, MMF) plus prednisone new triple therapy regimen, significantly reduce the occurrence of acute rejection after renal transplantation Rate; biological immunosuppressive drugs such as anti-thymocyte globulin, anti-lymphocyte globulin for the treatment of acute rejection, the reversal rate of 70% to 100%. However, there are some deficiencies in renal transplantation: ① obvious lack of kidney, ESRD patients waiting for prolonged renal transplantation; ② the current major immunosuppressive drugs are close to the amount of toxicity, it must be reasonable to use, and regularly determine the blood concentration to Adjust the dosage; ③ the body's immunosuppressive state caused by postoperative infection, the incidence of cancer increased; ④ renal transplantation after the primary disease recurrence, chronic kidney disease and other long-term survival of transplanted kidney.
In short, the doctor should be based on the patient's situation (including disease conditions, physical condition, vascular conditions, work conditions and living habits, economic conditions, etc.), combined with local medical and technical conditions, choose the most consistent with the patient's renal replacement therapy. If the patient's clinical and practical conditions permit, should be the first choice of peritoneal dialysis, with the gradual decline in residual renal function, gradually increase the dialysis dose to replace the residual renal function deficiency; later with the dialysis time, according to the patient Can change the dialysis method, from peritoneal dialysis to hemodialysis or renal transplantation; can also be changed from hemodialysis to peritoneal dialysis or renal transplantation; if the transplant failure can be changed back to dialysis integration therapy.
5. Strengthen the treatment of ESRD patients and the treatment of complications
Increasing the survival rate of ESRD patients is a comprehensive, long-term systematic project centered on renal replacement therapy. But there is still a considerable part of the lack of medical personnel ESRD treatment of the concept of integration, the renal replacement therapy simply as a technical operation, but not from the height of clinical treatment, the lack of comprehensive medical management and guidance of patients. All patients with chronic kidney disease develop metabolic product retention, water, electrolyte, acid-base balance disorders, and digestive system, blood system, cardiovascular system and other functional impairment, such as renal anemia, renal Bone malnutrition, high blood pressure, heart failure and so on. Reasonable correction of ESRD complications, can significantly improve the survival rate of patients, improve the quality of life of patients.
6. Strengthen the mental health guidance of ESRD patients
Patients with maintenance dialysis have a variety of psychological problems, such as depression, anxiety, depression, despair, and counterterrorism, due to illness, family and social factors, often degrading the quality of life of patients, and individual patients will stop dialysis and even commit suicide. This requires the kidney and psychological specialist medical staff to provide psychological guidance for patients. It is imperative that the majority of medical workers need to strengthen the awareness of ESRD integrated treatment, identify the treatment goals, for the support and cooperation of patients and their families, collaboration, in order to improve the survival rate of ESRD patients, quality of life and social regression rate and work together The
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