Nephrotic syndrome in the elderly

Introduction to elderly patients with nephrotic syndrome Nephrotic syndrome is a glomerular disease characterized by massive proteinuria (3.5g/d), hypoproteinemia (30g/d), hyperlipidemia and edema, and is a glomerular disease. Common performance. The senile nephrotic syndrome is divided into two major categories, one is primary nephrotic syndrome, which is one of the most common manifestations of primary glomerular disease; the second is caused by systemic diseases. For secondary nephrotic syndrome. basic knowledge The proportion of illness: 0.001% Susceptible people: the elderly Mode of infection: non-infectious Complications: lower extremity venous thrombosis pulmonary embolism acute renal failure acute tubular necrosis rapid progressive nephritis prerenal renal failure pulmonary edema

Etiology of elderly patients with nephrotic syndrome

(1) Causes of the disease

The incidence of recurrent nephrotic syndrome in elderly patients with nephrotic syndrome is high, among which renal amyloidosis is the highest, accounting for about 15% of all elderly patients with nephrotic syndrome, followed by various tumors, and often causes secondary nephropathy in the elderly. Syndrome, such as gastrointestinal tumors, lymphoma leukemia, lung cancer, 11%, and other diseases, such as senile diabetic nephropathy, hepatitis B, certain drugs (non-specific anti-inflammatory drugs, gold preparations, penicillamine) , vasculitis, cryoglobulinemia, macroglobulinemia, etc. In the primary nephrotic syndrome, pathological type is most common with membranous nephropathy. According to data from foreign 1980s, membranous nephropathy accounts for 36.5%. Small lesions accounted for 19.4%, various types of proliferative nephritis accounted for 15.3%, and focal glomerular sclerosis accounted for 7.7%. Other types were rare.

(two) pathogenesis

The etiology of glomerular disease has not been fully elucidated, and their pathogenesis is not the same, but immune factors can be considered as the main mechanism of their disease.

Elderly kidney disease prevention

Primary prevention

(1) Proper activities to stabilize emotions to increase immunity and disease resistance.

(2) Avoid cold, wet or excessive fatigue.

(3) Prevent colds, so as not to induce the disease.

(4) Avoid using drugs that are harmful to the kidneys.

(5) Regular review of related projects.

2. Secondary prevention

(1) Suffering from a cold and timely medication.

(2) timely treatment of infections in various parts of the body, pay attention to drug allergies when using drugs, so as not to induce aggravation of the disease.

(3) If proteinuria has appeared in the urine, the cause should be identified and treated promptly. Regularly review the condition, urine routine, blood lipids, plasma protein, and blood pressure.

(4) Minimize the use of drugs excreted by the kidneys during the period of decline in renal function, so as to avoid drug accumulation, drug poisoning, and increase kidney damage.

3. Three levels of prevention

The treatment is mainly based on the active treatment of the primary disease, reducing the damage of the disease to the kidneys.

Elderly patients with nephrotic syndrome complications Complications lower extremity venous thrombosis pulmonary embolism acute renal failure acute tubular necrosis rapid progressive nephritis prerenal renal failure pulmonary edema

Infection

When the elderly suffer from nephrotic syndrome, the body's immunity is significantly reduced under the action of hormones, which is prone to infection, and the infection is insidious. The clinical manifestations are not typical. The intrinsic is also easy to cause urinary tract infection, but there is nucleus in the urine. Do not easily diagnose urinary tract infections in cells. Urine culture should be done to distinguish whether it is a bacterial infection. Note that glucocorticoids often aggravate bacterial infections, especially susceptibility to tuberculosis infection. The use of cytotoxic drugs increases the susceptibility of the virus. Most of the infections are in the lungs, abdomen, meninges and lower urinary tract. Once the infection occurs, sensitive, potent and non-neotoxic antibiotics should be used in time. Precautions can be taken for the elderly, such as vaccination and high-immune serum. globulin.

2. Thrombosis, embolism

This is one of the most serious fatal complications. It has been recognized that there is a hypercoagulable state in nephrotic syndrome, which is related to changes in intrinsic coagulation, anticoagulation and fibrinolysis, and is associated with low protein and hyperlipidemia. Caused by blood concentration, increased blood viscosity makes the intrinsic coagulation, thrombosis tendency more serious, strong diuretic and long-term large amount of glucocorticoids, the incidence of thrombosis, embolism accounted for 8% to 50% of nephrotic syndrome Among them, renal vein thrombosis (RVT) is the most common, membranous nephropathy can reach 50% or more of patients, severe proteinuria, hematuria and even renal insufficiency can occur, followed by in situ thrombosis of pulmonary artery and pulmonary vein, surrounding Venous occurs in the deep venous thrombosis of the lower cavity and deep veins of the lower extremities. The incidence rate of adults is 6%, which is characterized by swelling of the lower extremities. The incidence of renal vein thrombosis, lower extremity venous thrombosis and pulmonary embolism is significantly higher than that of young adults.

3. Renal function damage

(1) idiopathic acute renal failure: the pathogenesis of this disease is still unknown, mostly occurred in the onset of nephrotic syndrome for about 1 month, no cause of sudden oliguria, hematuria, rapid deterioration of renal function, giving colloidal fluid Expansion can not only achieve diuretic effect, but also cause pulmonary edema, often need dialysis treatment, can naturally relieve, recovery takes about 7 weeks, this acute renal failure occurs in patients over 50 years old, pathologically diffuse interstitial edema, kidney Tubular epithelial cells degeneration, necrosis, shedding with regeneration, glomerular lesions are very light, more than 85% are mild lesions, because the patients are mostly middle-aged and elderly, often with small arteriolar hysteresis and elastic layer expansion, the disease needs to Identification of diseases:

1 rapid progressive nephritis;

2 non-sterol anti-inflammatory drugs caused by acute interstitial nephritis, may have nephrotic syndrome, often accompanied by systemic and renal allergy;

3 acute tubular necrosis caused by infection;

4 nephrotic syndrome complicated by acute renal failure caused by large renal vein thrombosis, can be diagnosed after eliminating the above reasons.

(2) acute prerenal renal failure: mainly due to insufficient blood volume, usually associated with severe hypoproteinemia and excessive use of strong diuretics, oliguria, no urine with insufficient blood volume (four limbs cold, body position Sexual blood pressure drops, pulse pressure is small, blood is concentrated, and hematocrit rises. At this time, plasma or expansion drug is input for treatment.

(3) renal tubular dysfunction: can cause diabetes, high phosphoric acid urine, loss of potassium and loss of bicarbonate, this symptom has poor effect on glucocorticoids, long-term prevention is also poor.

Symptoms of nephrotic syndrome in the elderly Common symptoms Facial edema, hypoproteinemia, protein, urine, urine, urine, sodium output, very low plasma albumin, high blood pressure, pericardial effusion, rheumatoid arthritis

The disease is often caused by infection (tonsitis, pharyngitis or general upper respiratory tract infection), or suffering from cold, fatigue, onset, acute onset, sometimes insidious onset, the main performance:

1. Edema: systemic, physical, concave edema, more common in the early part of the ankle, eyelids in the morning, facial edema, with the development of the disease, edema can reach the whole body and chest, abdominal cavity and scrotum effusion, and even Pericardial effusion, heart failure can occur in elderly patients with severe edema.

2. A large amount of proteinuria: urinary protein > 3.5g / 24h, severe cases up to a dozen grams, with selective or non-selective proteinuria.

3. Hypoproteinemia: The decrease of total plasma protein, mainly plasma albumin, is mostly in the range of 10 ~ 30g / L (1 ~ 3g / dl), occasionally down to 5.8g / L (0.58g / dl).

4. Hyperlipidemia: In most patients, blood cholesterol, phospholipids and triglycerides can be elevated. Among these 4 points, a large amount of proteinuria and hypoproteinemia are necessary for diagnosis.

Examination of elderly patients with nephrotic syndrome

1. Urine routine and renal function test: urine routine examination shows a large amount of proteinuria, only 15% to 20% of patients have microscopic hematuria, gross hematuria is rare, urine protein 24h3.5g, about 30% of patients at the beginning of the disease Mild creatinine increased, serum creatinine increased significantly in elderly patients, albumin <3.0g / dl, blood lipids, cholesterol, triglyceride was higher than normal.

2. Serum protein electrophoresis determination: mainly showed a decrease in albumin, an increase in 2 and 2 globulin, and a normal lower limit or decrease in gamma globulin.

3. Determination of urinary C3: The increase of C3 content in urine is mainly found in proliferative and sclerosing cases, and has reference value in the differential diagnosis of nephrotic syndrome.

4. Determination of urinary fibrin degradation products (FDP): This test is helpful for the type of nephrotic syndrome and the choice of treatment options. In the case of minor lesions, the urinary FDP<1.25g/ml is the majority, while the proliferative glomerulus The majority of nephritis>1.2g/ml, if the urine FDP>3g/ml, continue to not decrease, suggesting that the lesion activity is stronger.

Renal biopsy: This test can provide a morphological diagnosis for the determination of nephrotic syndrome and pathological types, and has a guiding significance for the treatment plan to determine and estimate the prognosis.

Diagnosis and diagnosis of elderly patients with nephrotic syndrome

Diagnostic criteria

The clinical manifestations of elderly patients with nephrotic syndrome are basically the same as those of adults. They are mainly determined according to the criteria of urine protein, plasma protein and blood triglyceride in the laboratory, and the nephrotic syndrome is secondary. Sexuality is more than primary, so it is clear that after the diagnosis of nephrotic syndrome, we must try to find out the cause. Because different kinds of reasons, different treatment options, outcomes and prevention are also very different. I have already mentioned senile nephrotic syndrome. Secondary to many diseases, various neoplastic diseases, gastrointestinal tumors, lymphoma, leukemia, lung cancer, multiple myeloma, as well as diabetic nephropathy hemangioma, abnormal proteinemia, systemic lupus erythematosus, certain drugs such as Gold preparations, penicillamine, non-steroidal anti-inflammatory, and conversion enzyme inhibitors, so the cause of the above diseases must be excluded in order to be diagnosed as primary nephrotic syndrome.

Various pathological types of nephrotic syndrome have different symptoms and causes:

1. Minimal lesion type: accounted for 25% of senile nephrotic syndrome. Clinical manifestations include diastolic hypertension and serum creatinine exceeding normal values, higher than adults, and hematuria is less than adults, with more primary.

2. Membranous nephropathy: 70% of senile nephrotic syndrome, membranous nephropathy type is often associated with tumors and certain drugs (gold preparation, penicillamine), tumors and lung tumors, gastrointestinal tumors, lymphoma, leukemia Related, clinical symptoms are not special.

3. Kidney amyloid: most of them are primary amyloidosis, a small number of secondary myeloma and chronic diseases, such as rheumatoid arthritis, when the amyloidosis can spread to the whole body, Congo red may appear in the gums or rectum Positive staining, and poor prognosis, no effective treatment, often died within 14 months after diagnosis.

The clinical diagnosis of typical nephrotic syndrome is not difficult, but due to aging changes in the kidneys of the elderly, and other systemic diseases can mask the performance of certain nephrotic syndromes, making them atypical and actually making accurate diagnoses. It is not easy, so in order to clarify the etiology of nephrotic syndrome and determine the appropriate treatment plan, many scholars believe that it is necessary to carry out renal biopsy, but because of kidney aging changes, sometimes combined with clinical data for analysis.

Differential diagnosis

Must be differentiated from secondary nephrotic syndrome.

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