Mob ntshav qab zib nephropathy yog hais txog kev mob txhab rau qee qhov ntawm lub raum ua rau muaj mob tshwm sim vim qhov tshwm sim ntawm cov khoom noj ntawm cov zaub mov muaj protein thiab lipids hauv lub cev. Cov kab mob hloov pauv yuav cuam tshuam rau lub raum glomeruli, tubules, hlab ntsha, thiab hlab ntsha. Mob ntshav qab zib nephropathy tshwm sim hauv 70-75% ntawm cov neeg uas muaj "kab mob qab zib".
Nws feem ntau nws ua tiav nws tus kheej hauv daim ntawv ntawm cov xwm txheej hauv qab no:
- Sclerosis ntawm lub raum plab hlaub thiab nws cov ceg.
- Sclerosis ntawm txoj hlab ntsha.
- Glomerulosclerosis ntawm diffuse, nodular thiab exudative hom.
- Pyelonephritis.
- Necrosis ntawm lub raum papilla.
- Necrotic Nephrosis.
- Kev tso tawm rau hauv txoj hlab hlaws ntawm cov tshuaj mucopolysaccharides, lipids thiab glycogen.
Kev tsim kho tshuab
Lub pathogenesis ntawm ntshav qab zib nephropathy cuam tshuam nrog ib tug xov tooj ntawm cov metabolic thiab hemodynamic yam. Thawj pawg muaj xws li hyperglycemia (ntshav qab zib cov ntshav siab) thiab hyperlipidemia (qib ntawm lipids thiab / lossis lipoproteins hauv cov ntshav). Hemodynamic yam yog sawv cev los ntawm kev mob ntshav txhaws thiab nce siab sab hauv lub raum glomeruli.
Tseem Ceeb! Kuj tseem muaj qhov kev mob tshwm sim keeb kwm uas tsis tuaj yeem txo nqi.
Kev pauv hloov pauv
Hyperglycemia yog qhov sib txuas tseem ceeb hauv cov saw hlau ntawm kev txhim kho pathology ntawm lub raum tawm tsam keeb kwm ntawm "kab mob qab zib". Tawm tsam tom qab ntawm qib siab ntawm cov piam thaj, nws koom nrog cov protein thiab cov rog ntawm lub raum ua haujlwm, uas hloov lawv lub cev nqaij daim tawv thiab lub cev zoo. Tsis tas li ntawd, muaj coob leej ntawm monosaccharides zoo ntxim rau cov ntaub so ntswg ntawm cov kabmob, uas ua rau cov khoom tsim cov protein kinase C thiab pab txhawm rau nce permeability ntawm lub vascular phab ntsa.
Hyperglycemia yog qhov tseem ceeb etiological nyob rau hauv kev txhim kho kev mob ntshav qab zib
Kev ua kom lub zog ntawm oxidation ua rau ua rau tso tawm cov dawb radicals uas tuaj yeem muaj qhov tsis zoo thiab muaj kev cuam tshuam hauv lub cev.
Theem ntau ntawm cov lipids thiab lipoproteins hauv cov ntshav yog qhov cuam tshuam tshiab ntawm kev txhim kho ntawm cov nephropathy. Muab tso rau txheej sab hauv ntawm cov hlab ntsha thiab cov hlab ntsha, cov kua nplaum ua rau nws puas tsuaj thiab nce permeability. Tsawg lipoproteins uas tau ua haujlwm tiv thaiv oxidation muaj peev xwm txeem tau los ntawm txheej sab hauv ntawm cov hlab ntshav. Lawv raug ntes los ntawm cov hlwb tshwj xeeb puag ncig uas cov nqaij sib txuas tau pib ua.
Hemodynamic yam
Qhov siab ntawm lub siab nyob rau hauv glomeruli ntawm ob lub raum yog qhov ua rau muaj kev vam meej ntawm pathology. Qhov ua rau cov ntshav tsis txaus siab yog kev ua haujlwm ntawm renin-angiotensin system (cov tshuaj hormones-active tshuaj angiotensin-II).
Kev nce ntxiv ntawm cov ntshav siab nyob hauv tib neeg lub cev uas tshwm sim hauv kev teb rau txhua yam ntawm cov saum toj no dhau los ua kev hloov kho uas muaj kev hloov pauv ntawm cov kev hloov pauv hauv kev txhim kho ntxiv ntawm lub raum pathology hauv nws lub zog pathological.
Cov ntaub ntawv Master
Mob ntshav qab zib nephropathy (code rau ICD-10 - N08.3 lossis E10-E14 p. 2) feem ntau tshwm sim tiv thaiv keeb kwm ntawm cov ntshav qab zib insulin-tiv thaiv mob ntshav qab zib mellitus. Nws yog nrog hom 1 tus kab mob uas lub raum pathology yog thawj qhov chaw ntawm txhua qhov ua rau muaj kev tuag nyob hauv cov neeg mob. Nrog hom 2, mob nephropathy yog zaum thib ob (thawj zaug yog qhov mob ntawm lub siab thiab cov hlab ntsha).
Lub raum yog lub lim uas ua kom cov ntshav ntawm cov tshuaj lom, cov khoom lag luam metabolic, cov tshuaj lom. Tag nrho cov no yog tawm hauv cov zis. Glomeruli ntawm ob lub raum, nyob rau hauv uas hloov pauv hauv ntshav qab zib, suav hais tias yog kev lim dej. Qhov tshwm sim yog kev ua txhaum ntawm cov txheej txheem ntuj thiab qhov sib npaug ntawm electrolytes, kev noj cov protein nyob hauv cov zis, uas tsis pom hauv cov neeg noj qab haus huv.
Glomeruli ntawm ob lub raum - lub ntsiab qhov tseem ceeb ntawm cov ntshav pom
Qhov no tshwm sim raws li cov phiaj xwm hauv qab no:
- Cov theem thaum ntxov - cov protein tsawg tshaj plaws nkag mus.
- Kev nce qib - cov lwg loj loj ntog.
- Ntshav siab nce, uas ntxiv kev cuam tshuam lub raum ua haujlwm.
- Ntau dua kev puas tsuaj rau lub cev nce siab dua BP.
- Qhov uas tsis muaj protein ntau hauv lub cev ua rau muaj qhov mob edema thiab qhov tsim ntawm CKD, uas yog los ntawm kev qog tsis ua haujlwm.
Yog li, peb tab tom tham txog lub voj voos tsis zoo, qhov txiaj ntsig ntawm qhov uas yuav tsum tau muaj mob hemodialysis, thiab nyob rau kis mob hnyav, lub raum hloov ntshav.
Kev faib tawm
Muaj ntau txoj kev sib kis ntawm tus kabmob rau menyuam yaus thiab cov neeg laus: cov chaw kuaj mob, kev faib tawm morphological thiab kev faib tawm los ntawm theem.
Soj ntsuam
Hauv kev muaj protein nyob rau hauv cov zis, cov qib creatinine hauv cov ntshav tau txiav txim siab. Ntxiv mus, raws li cov qauv txheej txheem, glomerular filtration rate tau muab xam, raws li qhov ntsuas ntawm qhov uas muaj CKD thiab nws theem tau txiav txim siab.
Cov qauv rau kev ntsuas tus nqi ntsuas pom hauv cov neeg laus:
140 - hnub nyoog (pes tsawg xyoo) x lub cev hnyav (hauv kg) x coefficient. (txiv - 1.23, poj niam - 1.05) / creatinine (μmol / L) = GFR (ml / min)
Cov qauv rau kev ntsuas GFR rau menyuam:
txawv (nce raws hnub nyoog) x qhov siab (cm) / creatinine (μmol / L) = GFR (ml / min)
| CKD Theem | Npe | GFR qhov ntsuas (ml / min) |
| Kuv | Lub xub ntiag ntawm cov kab mob kev txiav txim siab los ntawm lwm txoj kev kuaj mob, nrog rau qhov qub lossis nce tus nqi ntawm kev pom kev | 90 thiab saum toj no |
| II | Pathology ntawm lub raum nrog cov zauv loj ntawm kev pom kev txhaws | 60-89 |
| III | Ntsuas lim txaus kom txo kev ceev | 30-59 |
| IV | Cim qhov txo qis hauv glomerular pom kev npaum li cas | 15-29 |
| V | Raum tsis ua haujlwm | 14 thiab qis dua |
Morphological
Muaj plaub chav kawm tseem ceeb, raws li qhov uas lub cev kev xav thiab lub cev hloov pauv hauv tus neeg mob lub cev tau teev tseg.
- Thickening ntawm daim nyias nyias ntawm txoj hlab raum ntawm qhov raug rho tawm.
- Dilation ntawm glomerular intervascular cell ntawm muaj hnub nyoog (a) lossis hnyav (b) hom.
- Qhov tsim muaj cov hnoos qeev hauv cov hlwb intervascular (glomerulosclerosis).
- Sclerosis ntawm qhov hais tawm.
Kev faib tawm theem
Thawj theem yog pom los ntawm hyperfunction ntawm kev pom. Nws pib mob ntshav qab zib thaum pib. Lub raum sim tshem tawm cov piam thaj hauv lub cev sai li sai tau, suav nrog kev ua haujlwm ntawm kev tiv thaiv. Proteinuria (protein nyob hauv cov zis) yog tsis tuaj, raws li cov cim ntawm pathology.
Qhov thib ob theem yog qhov pib tshwm sim. Nws tshwm sim ntau xyoo tom qab kev kuaj mob ntawm "kab mob qab zib". Cov phab ntsa ntawm cov hlab ntsha thiab cov hlab ntsha thicken, tab sis tsis muaj protein hauv cov zis, ntxiv rau cov tsos mob hauv kev kuaj mob.
Qhov thib peb theem yog theem ntawm microalbuminuria. Kev kuaj sim ntsuas pom qhov muaj protein nyob hauv qhov ntau ntawm 30 txog 300 mg / hnub. Vascular kev puas tsuaj yog manifested los ntawm sij hawm nce nyob rau hauv cov ntshav tsis muaj lwm yam tshwm sim.
Urinalysis - lub hauv paus rau kev kuaj mob ntshav qab zib nephropathy
Qeb plaub - cov tsos mob hnyav ntawm mob ntshav qab zib nephropathy. Qhov ntau npaum li cas ntawm cov protein tau tawm hauv cov zis, qhov ntsuas ntawm cov protein nyob rau hauv cov ntshav txo qis, thiab puffiness tshwm. Yog hais tias theem ntawm cov proteinuria nyob hauv nruab nrab, edema tshwm rau ntawm lub ntsej muag thiab txhais ceg. Nyob rau hauv cov ntaub ntawv ntawm excretion ntawm ib tug loj npaum li cas ntawm cov protein los ntawm lub cev, pathological exudate accumulates nyob rau hauv lub plab, pleural, pericardial kab noj hniav.
Qeb tsib yog qhov mob tseem ceeb uas ua los ntawm kev ua tiav sclerosis ntawm lub raum hlab ntsha, GFR tsawg dua 10 ml / min. Kev pab muaj nyob hauv hemodialysis lossis hloov khoom nruab nrog, vim lwm txoj kev kho yog tsis ua hauj lwm zoo lawm.
Soj ntsuam duab
Cov theem ntawm ntshav qab zib mob hlwb sib cuam tshuam nrog kev pom thiab kuaj pom. Thawj peb theem tau txiav txim siab preclinical, txij li tsis muaj qhov pom ntawm lub pathology. Kev hloov tsuas yog txiav txim siab siv lub chaw kuaj mob los yog thaum lub sij hawm tshawb nrhiav keeb kwm ntawm lub raum.
Cov tsos mob hnyav tshwm sim nyob rau theem plaub, thaum cov neeg mob pib yws txog cov tsos mob hauv qab no:
- o ntawm lub ntsej muag thiab qis dua qhov kawg;
- nce ntshav siab;
- poob phaus;
- kev ua kom tsis muaj zog, txo qis;
- xeev siab, ntuav
- tsis muaj qab los noj mov;
- pathological nqhis dej;
- cephalgia;
- txog siav
- mob qab pob tw.
Kev taw qhia rau tsev kho mob
Kev kho mob rau cov neeg mob yog npaj raws li tau npaj tseg rau cov neeg mob nephropathy thiab tiv thaiv nephrotic syndrome nrog tus lim ntshav siab dua 65 ml / min, nrog cov kab mob raum nrog cov mob raum ntev ntawm qib 3 thiab 4.
Yuav tsum tau mus pw hauv tsev khomob xwmtxheej ceev hauv qab no:
- oliguria - ib txoj hlab ntshav me me uas tso zis;
- azotemia - ib qho kev nce ntxiv ntawm cov tshuaj nitrogenous hauv cov ntshav;
- hyperhydration - pathology ntawm dej-ntsev ntsev cov metabolism, tus cwj pwm los ntawm kev tsim ntawm edema;
- metabolic acidosis - kev nce ntxiv hauv cov ntshav acidity;
- hyperkalemia - ib qho kev nce poov tshuaj ntau ntxiv hauv cov hlab ntshav.
Lub tswv yim ntawm kev tswj hwm tus neeg mob thiab txiav txim siab qhov xav tau pw hauv tsev kho mob yog qhov tseem ceeb ntawm tus kws kho mob tuaj koom
Kev kuaj mob pathology
Tus kws kho mob tshwj xeeb qhia meej tus neeg mob kuaj ntshav qab zib, theem ntawm ntshav siab thiab nws qhov sib txawv, kev txhim kho o. Kev soj ntsuam pom qhov mob ntawm daim tawv nqaij, tus neeg mob lub cev qhov hnyav, qhov muaj nyob ntawm edema thiab lawv qhov mob hnyav, qhov sib piv ntawm cov zis tau txais thiab tawm ntawm ib hnub.
Kev kuaj ntshav dav dav (tus naj npawb ntawm cov khoom tsim, coagulation xeev, leukocyte mis, ESR), biochemistry (tag nrho cov protein, albumin, C-reactive protein) yog qhov yuav tsum tau ua. Cov zis muaj nuj nqi yog raug ntsuas (kev tshuaj xyuas dav dav, kev sojntsuam qog qis, ELISA ntawm cov protein, kab mob kab mob).
Cov qib ntawm GFR, creatinine, urea, cov roj cholesterol, piam thaj, thiab cov ntsiab lus raug txiav txim siab. Lwm txoj kev kuaj mob:
Ntshav qab zib Angiopathy- Ultrasound ntawm ob lub raum thiab plab;
- cov nqaij mos rau lub raum;
- ECG, echocardiography;
- Dopplerography ntawm cov hlab ntsha;
- Xoo hluav taws xob ntawm lub hauv siab, plab;
- Qhov ntsuas ntawm cov thyroid thiab parathyroid cov tshuaj hormones.
Yog tias tsim nyog, tus kws kho mob xa tus neeg mob rau kev sab laj nrog tus kws kho mob (tsis suav nrog tus mob ntshav qab zib), tus kws kho plawv (thaum lub cim ntawm lub plawv tsis ua haujlwm thiab tsis tuaj yeem), tus kws kho mob endocrinologist (los tswj tus kab mob hauv qab), tus kws kho mob hlwb (kom tsim muaj AV fistula raws li nkag mus rau hemodialysis).
Kev sib txawv ntawm kev kuaj mob
Mob ntshav qab zib nephropathy yuav tsum paub qhov txawv ntawm cov nephrotic syndrome thiab mob nephritic syndrome.
| Cov chaw kuaj mob | Tus mob Nifaisrotic | Cov leeg mob nephritic | Ntshav qab zib ntshav qab zib |
| Pib theem | O o ntawm ceg thiab lub ntsej muag tshwm tuaj | Ntshav lossis protein nyob hauv cov zis, o, ntshav nce siab | Cov ntaub ntawv ntshav qab zib, nce siab hauv siab |
| O o thiab tawv nqaij mob | Tseem ceeb o | Me me o | Nrog rau kev nce ntxiv hauv cov protein nyob hauv cov zis, edema ua rau hnyav ntxiv, yuav muaj kab mob trophic |
| HUAB TAIS | Li qub lossis txo qis | Ntau zaus nyob rau hauv ib txwm txwv | Ntau qib |
| Cov ntshav nyob hauv cov zis | Tsis muaj, tshwm sim thaum ua ke nrog nephritic syndrome | Tas li | Puas muaj lawm |
| Protein hauv zis | Ntau tshaj li 3.5 g / hnub | Hauv qab 3 g / hnub | Los ntawm insignificant rau lossis loj ntsuas |
| Muaj cov khoom lag luam ntawm nitrogenous hauv cov ntshav | Muaj ntau zuj zus thaum cov kab mob loj zuj zus tuaj | Ploj los yog loj hlob qeeb heev | Nyob ntawm seb qhov mob ntev li cas |
| Lwm yam kev qhia paub | Cov txuam nrog exudate nyob rau sab hauv cov kab noj hniav | Systemicity hauv hemorrhagic syndromes | Kev puas tsuaj rau lub tsom xam pom, mob taw ko taw, sab laug ventricular hypertrophy |
Kev tswj tus neeg mob lub cev cov ntsiab lus
Nrog rau kev loj hlob ntawm CKD theem 1 thiab 2, nrog rau kev nce ntshav siab, kev noj zaub mov zoo yuav tsum muaj, kev noj zaub mov kom muaj protein txaus hauv lub cev. Cov calories rau txhua hnub yog xam los ntawm tus kheej los ntawm tus kws endocrinologist lossis tus kws noj zaub mov ua zaub mov noj. Kev noj zaub mov noj suav nrog kev txwv kom tsawg nyob rau hauv cov ntsev muab rau lub cev (tsis pub dhau 5 g hauv ib hnub).
Txwv txiav cov ntsev ntau nyob hauv qhov khoom noj - muaj peev xwm txo qis kev loj hlob ntawm puffiness
Cov tsoomfwv ntawm kev ua lub cev tau teeb tsa rau ib nrab ib teev txog 5 zaug hauv ib asthiv. Tsis kam nrog kev coj tsis zoo (haus luam yeeb thiab haus dej). Txhua 3 lub hlis ib zaug, nws yog qhov yuav tsum tau txiav txim siab muaj cov protein nyob hauv cov zis, thiab ntsuas ntshav siab txhua hnub.
Tus kws kho keeb endocrinologist kho qhov txheej txheem los ntawm insulin txoj kev kho lossis siv cov tshuaj tiv thaiv hypoglycemic, yog tias tsim nyog, coj kev kho los ntawm kev rho tawm lossis ntxiv ib yam tshuaj noj. Qhov no tseem ceeb vim tias hyperglycemia yog qhov tshwm sim hauv kev txhim kho rau cov ntshav qab zib ua kom tsis muaj mob nephropathy.
Siv tshuaj kho
Lub sijhawm tseem ceeb hauv kev kho mob ntshav qab zib nephropathy yog kev txo ntshav siab rau cov lej ib txwm (hauv qhov muaj protein nyob hauv cov zis, ntshav siab yuav tsum qis dua 130/80 hli Hg). Tshuaj uas xaiv:
- ACE inhibitors (Perindopril) - tsis tsuas yog txo cov ntshav siab, tab sis kuj txo cov protein cov paug hauv cov zis.
- Angiotensin receptor blockers (Losartan, Eprosartan) - txo cov ntshav siab, txo qis kev ua haujlwm ntawm lub raum.
- Thiazide diuretics (Indapamide, Clopamide) - ua haujlwm zoo thaum ntxov, thaum cov kev ntsuas pom yog siab tshaj 30 ml / min.
- Ntxees diuretics (ethacrine acid, furosemide) - yog kho nyob rau theem ua kom pom tseeb tiag tiag ntawm nephropathy.
- Beta-blockers (Atenolol, Metaprolol).
- Cov calcium tubule blockers (Verapamil).
Txhawm rau txo qis kev ua haujlwm ntawm lipoproteins tsawg kawg, statins (Simvastatin, Atorvastatin) thiab cov fibrates (Ciprofibrate, Fenofibrate) yog tshuaj.
Hemodialysis
Cov ntaub ntawv kho mob niaj hnub no tsis muaj cov lus qhia pom meej txog qhov tseeb thaum nws yuav tsum pib ntxuav ntshav los ntawm hemodialysis. Kev txiav txim siab qhov xav tau yog qhov tseem ceeb ntawm tus kws tshaj lij tau koom nrog. Nyob rau xyoo 2002, European Practical Guide tau tshaj tawm, uas muaj cov ntaub ntawv hauv qab no:
- Kev ntxuav los ntawm kev lim ntshav yuav tsum pib yog tias glomerular pom kev qis dua 15 ml / min hauv kev sib xyaw nrog ib lossis ntau qhov tshwm sim: kev o, kev kub siab tsis tuaj yeem tswj tau thiab kho, qhov kab mob ntawm cov khoom noj khoom haus zoo, yam ntxwv ntawm kev muaj mob.
- Cov ntshav ua kom huv yuav tsum pib nrog GFR qis dua 6 ml / min, txawm hais tias kev kho mob zoo tshaj plaws, thiab tsis muaj kev qhia ntxiv.
- Kev lim ntshav thaum ntxov rau cov neeg mob uas muaj kev pheej hmoo siab.
KDOQI cov lus pom zoo hais tias kev lim ntshav yuav tsum pib ua raws li cov kev mob hauv qab no:
- tseem ceeb edema, tsis yog amenable mus kho nrog cov tshuaj;
- tus nqi lim ntshav tsawg dua 15 ml / min;
- urea - 30 mmol / l thiab hauv qab;
- tus cwj pwm tsis txaus ntseeg txo qis thiab nce qib ib txwm muaj;
- ntshav poov tshuaj yog tsawg dua 6 mmol / l.
Hemodialysis - txoj kev kho vajtse cov ntshav ua kom lub zog ua haujlwm ntawm lub raum tsis ua haujlwm
Kev phais mob
Tus neeg mob uas mob ntshav qab zib nephropathy yuav tau npaj lossis siv sijhawm phais sai. Rau kev raug lim ntshav sai sai yam tsis muaj kev nkag, yuav tsum tau lim ntshav ib ntus txuas mus ntxiv.
Cov kev ua haujlwm npaj ua haujlwm yog qhov tsim ntawm txoj hlab dej fistula, cog cov leeg ntshav txhaws, ruaj khov los yog peritoneal catheter. Stenting lossis zais zais angioplasty ntawm cov hlab ntsha hauv lub raum tseem tuaj yeem ua.
Kev tiv thaiv kev ntsuas
Lub hauv paus rau kev tiv thaiv ntawm nephropathy thiab lwm yam mob hnyav yog nyiaj them rau ntshav qab zib. Yog hais tias tus kab mob pathology twb tshwm sim, thiab albumin hauv cov zis tau kuaj pom, nws yog qhov yuav tsum tau ua kom qeeb ntawm qhov muaj mob ntawm cov mob uas yog hauv qab no:
- kev ntsuas tus kheej cov ntshav qab zib cov cim;
- ntsuas ntshav ntsuas txhua hnub;
- rov qab los ua cov ntaub ntawv roj ntshav cev;
- siv tshuaj kho;
- ua raws li kev noj haus ntawm cov zaub mov uas tsis muaj carbohydrate.
Nrog kev txhim kho ntawm cov proteinuria hnyav, yuav tsum ua raws li cov lus pom zoo hauv qab no:
- kev ua tiav ntawm kev pom glycated hemoglobin (qis dua 8%);
- kev hloov kho ntawm cov ntshav ntsuas (ntau tshaj yog tso cai cov nuj nqis - 140/90 hli Hg);
- kev nqus ntawm qhov tseem ceeb ntawm cov protein nrog zaub mov.
Hmoov tsis zoo, tsuas yog thawj theem pib ntawm qhov tshwm sim yog suav tias yog thim rov qab. Tus so yog kho tsis tau. Cov kws kho mob tshwj xeeb tsuas tuaj yeem ua rau qeeb zuj zus ntawm tus kab mob, tuav tus neeg mob txoj kev noj qab haus huv zoo. Kev kuaj mob kom raws sij hawm thiab ua raws li cov lus qhia ntawm cov kws kho mob yog tus yuam sij rau qhov txiaj ntsig zoo rau cov neeg mob.
