Nephrology for the Family Physician - O.I. Bakaliuk 2003

Medical surveillance and health resort treatment for kidney diseases

Outpatient care and clinical monitoring (dispensary observation) of patients with Kidney diseases require urgent and close attention from the healthcare system.

This is primarily because nephropathies of various etiologies predominantly affect young people. Under their natural course, over a period ranging from 6 months to 15–20 years, they lead to The Development of end-stage renal failure, where mortality can be prevented only through maintenance hemodialysis or kidney transplantation.

Secondly, outpatients primarily present with dysuria, edema, and Hypertension; therefore, at this stage, timely Diagnosis of renal pathology is crucial to clarify its nature and determine further appropriate medical management (outpatient or inpatient examination and Treatment).

Thirdly, patients return to this stage after diagnosis clarification to continue active treatment prescribed in the hospital, monitor the further course of the disease, prevent complications associated with active therapy, thoroughly treat intercurrent diseases, sanitize foci of chronic infection, and correct hypertension and Metabolic Disorders (acidosis, Osteoporosis, hypo- or hyperkalemia, hypocalcemia, etc.). Thus, this stage is the most labor-intensive.

Clinical monitoring is indicated for individuals with the following diseases and conditions:

1. Acute GN with a protracted course (up to 12 months from the onset of the disease).

2. Convalescents after acute GN.

3. Chronic GN.

4. Rapidly progressive GN.

5. ACUTE RENAL FAILURE (period of convalescence).

6. Chronic renal failure.

7. Renal Involvement in systemic diseases.

8. Women who have experienced Preeclampsia or Eclampsia.

9. Diabetic nephropathy.

10. Renal Amyloidosis.

11. Acute renal failure.

12. Chronic renal failure resulting from other kidney diseases.

Among the listed conditions, acute and chronic GN undoubtedly occupy a leading place.

Clinical monitoring of patients recovering from acute GN involves the early detection of disease relapse and the continuation of therapy initiated during the inpatient stage. The duration of follow-up is two years in cases of a benign disease course, and five years in cases of unstable normalization of clinical and laboratory parameters.

In addition to medical Nutrition therapy (dietotherapy), an important role belongs to identifying and eliminating risk factors for the chronization of the disease (frequent viral or bacterial infections, diseases of other Organs and systems, allergic reactions, exposure to nephrotoxic substances, use of nephrotoxic medications, excessive physical exertion, hypothermia, etc.), as well as preventing complications associated with The Use of high doses of glucocorticoids and immunosuppressants. Prophylactic and therapeutic vaccinations are contraindicated for all patients.

If high-dose corticosteroid monotherapy was used during previous inpatient treatment, and provided it is well tolerated and accompanied by constant monitoring for side effects, such therapy is continued as an alternating-regimen course—that is, the long-term (up to 1 year or more) use of high therapeutic doses (60–80 mg/day) of prednisolone every other day.

The achieved effect can also be maintained by using maintenance doses of prednisolone (25–30 mg/day) alone or in combination with a cytostatic agent (azathioprine at 50–100 mg/day).

If a cytostatic agent was used at the hospital stage, its administration should be continued on an outpatient basis for at least 5–6 months. The drug must be temporarily discontinued if the Blood leukocyte count drops to 3.5 ∙ 10 ⁹/L.

The four-drug therapy prescribed in the hospital is continued on an outpatient basis (for 6–18 months). Here, heparin is replaced by an indirect anticoagulant (phenindione, warfarin), and the daily dose of prednisolone is slowly tapered (by 5–10 mg/week) until a dose of 25–30 mg/day is reached. The prothrombin index is maintained within the range of 60–70%.

Therapy with indomethacin or another NSAID is usually continued at the same dose (50–150 mg/day).

When monitoring patients with chronic GN, the stage of the disease (prehypertensive, hypertensive, or renal failure stage) must be taken into account.

Particular attention should be paid to the management of arterial hypertension (aiming to normalize BP levels), metabolic disorders (hypo- or hyperkalemia, hypocalcemia, acidosis), and anemia. Ophthalmologists, neurologists, otolaryngologists, and cardiologists are involved in the follow-up care program.

The scope and frequency of follow-up examinations for GN are presented in Table 14.

Indications for unscheduled hospitalization in acute and chronic GN include worsening signs of NS, elevated BP levels, deterioration of renal function, thrombotic complications, and concurrent intercurrent diseases.

The follow-up care program for children who have suffered from GN provides for:

- arranging an adequate school schedule and proper rest conditions at home;

- diet therapy;

- sanation of chronic infection foci;

- continuation of therapy initiated in the hospital;

- monitoring Adverse effects of pharmacotherapy;

- addressing the issue of scheduled vaccinations;

- timely treatment of intercurrent diseases.

Class="center">Frequency and scope of follow-up observation in patients with GN (M.B. Velychko et al., 1993)

In case of complete remission within the first 5-6 months after discharge from the hospital, follow-up examinations are carried out monthly, subsequently every 2-3 months During the first year, and thereafter once every 6 months.

Scope of outpatient examinations: complete blood count, urinalysis, Nechyporenko urine test, Zimnitsky and Reberg-Tareyev tests, urinary pH determination, titratable acidity, ammonia excretion, blood levels of total protein and protein fractions, Cholesterol, triglycerides, urea, creatinine, potassium, sodium, calcium, and consultations with an ophthalmologist, ENT specialist, and dentist.

Whenever possible, serum levels of middle molecules, major immunoglobulin classes, circulating immune complexes (CIC), T-Cell Immunity activity, and acute-phase inflammatory markers should also be determined.

During the first months of follow-up, routine urinalysis is performed once every 2 weeks, then once a month; other tests are performed as needed, but at least once every 6 months.

The frequency and scope of tests for other kidney diseases are determined individually, depending on the form of the pathology, its clinical course, and the functional state of the Kidneys.

In acute Pyelonephritis, follow-up observation is carried out for 2 years with examinations twice a year. In addition to complete blood and urine tests, the dynamics of leukocyturia, degree of bacteriuria, nature of urinary flora, and the Zimnitsky test (in case of decreased specific gravity in the morning urine portion) are evaluated.

Individuals with Chronic Pyelonephritis are examined 4 times a year, and serum creatinine, urea, and electrolytes are measured once or twice a year.

Patients with Collagen-induced GN are subject to follow-up by a rheumatologist with the mandatory participation of a nephrologist. The frequency of follow-up examinations ranges from once a month during active disease to 3 times a year during clinical and laboratory remission; The Scope of examinations is the same as for chronic GN.

Pregnant women with chronic GN are hospitalized in a specialized nephrology department to clarify the form, stage of the disease, and functional state of the kidneys. Based on these data, the issue of continuing or terminating the Pregnancy is addressed.

If chronic GN is complicated by nephrotic syndrome or arterial hypertension in pregnant women, they should be re-hospitalized 3 weeks before delivery.

Women with a history of preeclampsia whose symptoms persist at least partially after childbirth are subject to follow-up observation for 1 year; blood and urine tests are performed once every 2 months, and blood creatinine levels are checked once every 4 months. In case of preeclampsia transformation into Essential Hypertension or chronic GN, patients are transferred to the respective follow-up groups.

Patient follow-up for DN is carried out jointly with an endocrinologist, involving monitoring of BP, glycemia, lipid profile, and signs of Urinary Tract infection. The St. Vincent Declaration guidelines specify the optimal timing for referring a DN patient to a nephrologist at a creatinine level of 0.2 mmol/L (S.I. Ryabov et al., 1999). General blood and urine tests, fasting blood glucose, glycemic profile, daily proteinuria, as well as serum creatinine, glucosuria, and acetonuria levels are mandatory for this patient group. The frequency of dispensary follow-up is 3–4 times per year for persistent proteinuria and 4–6 times per year for chronic RF. In cases of diabetic macroangiopathy, such patients are examined by an ophthalmologist, surgeon, and neurologist 1–2 times per year.

Patients in the proteinuric stage of renal amyloidosis are examined twice a year, and 4 times a year upon the development of NS or CRF. The scope of diagnostic tests is the same as for the corresponding forms of chronic GN. Consultation with other specialists (such as a hematologist, rheumatologist, phthisiologist, or orthopedist) is considered appropriate depending on the underlying pathology that triggered this condition.

Patients who have suffered acute RF are monitored for 2 years, with check-ups scheduled once a month for the first six months and once every 3 months thereafter. At each visit, general clinical blood and urine tests are performed, along with the Zimnitsky test; serum creatinine, urea, and electrolytes are measured once every 3 months. If renal function has not fully recovered within the 2-year follow-up period, the patient is transferred to the "Chronic GN" dispensary group, or to the "Chronic PN" group if a urinary tract infection develops.

In the initial stage of CRF (creatinine levels within 0.25–0.27 mmol/L), dispensary examinations are conducted twice a year; in moderate CRF (0.28–0.54 mmol/L), once every 3 months; and in severe CRF (above 0.55 mmol/L), once every 2 months. In addition to routine Laboratory tests, the status of electrolyte, nitrogen, and Lipid METABOLISM is assessed (every 4–6 months in the absence of special indications), and ECG and fundus examinations are performed at least twice a year.

Patients who have undergone surgery for renal trauma, as well as those treated conservatively, remain under dispensary supervision for 2 years. The frequency of examinations is once a month for the first six months, once every 3 months for the next six months, and once every 6 months thereafter. At each visit, general clinical blood and urine tests, the Zimnitsky test, and ultrasound are performed, and serum levels of creatinine, urea, and electrolytes are determined every 3 months.

Sanatorium-resort treatment plays a significant role in the comprehensive secondary Prevention program for kidney diseases.

Below are the main resorts in Ukraine and the countries of the former USSR: desert and semi-desert climate resorts (Bairam-Ali, Kolla-Kara, Jalal-Abad, Bukhara), climatic resorts (Southern Coast of Crimea), and balneotherapeutic resorts and sanatoriums (Borjomi, Darasun, Jermuk, Yessentuki, Kyzyl-Tepe, Krayinka, Pärnu, Tashkent Mineral Waters, Yumatovo, Yangantau, Berezivski Mineral Waters, Myrhorod, Staraya Russa, Truskavets, Poliana, Solnechnoe Zakarpatye, Kvitka Polonyny, Husiatyn, Sataniv).

Desert climate resorts are indicated for patients with acute GN (no earlier than 10–12 months from disease onset) or with latent chronic GN, urinary syndrome, preserved or moderately reduced renal function, and labile AH; as well as those with chronic GN complicated by NS without severe hypoproteinemia.

Climatic resorts are indicated for patients with acute GN (no earlier than 10–12 months from disease onset) in the phase of complete clinical remission with isolated urinary syndrome and minimal or moderate AH; chronic GN with urinary syndrome and preserved or moderately reduced renal function; and chronic GN in the hypertensive stage (BP not exceeding 180/100 mmHg) with preserved or moderately reduced renal function.

Balneological resorts provide treatment for patients with acute or chronic PN (no earlier than 3 months after the resolution of active inflammation), uric acid diathesis, urolithiasis, and Gout with renal involvement.

The main contraindications for referring patients with kidney diseases to sanatorium-resort treatment include: creatininemia above 0.22 mmol/L, AH above 180/100 mmHg with retinopathy, NS with severe hypoproteinemia, gross Hematuria of various etiologies, Hydronephrosis, urolithiasis requiring surgical intervention, and other conditions and diseases (malignant neoplasms, blood disorders, cachexia, active tuberculosis, pregnancy, and Heart Failure above stage I).