Poj Niam Kev Loj Hlob Thiab Gynecologic Considerations nyob rau hauv Mob raum Kab Mob: Kev Laus Thiab Hluas Laus Ⅰ

Mob raum mob(CKD) cuam tshuam rau cov hluas, suav nrog cov hluas thiab cov hluas. CKD ntawm cov poj niam yog nrog los ntawm kev txhawj xeeb txog kev xeeb tub thiab gynecological; tab sis txog niaj hnub no, thaj chaw no tsis tau kawm zoo. Hormonal cuam tshuam los ntawm CKD tuaj yeem ua rau muaj qhov tshwm sim ntawm qhov txawv txav ntawm lub tsev menyuam los ntshav thiab cuam tshuam rau lub hnub nyoog ntawm menarche hauv cov tub ntxhais hluas. Lub sijhawm kev txom nyem raws li kev cuam tshuam kev lag luam hauv zej zog ntxiv ua rau cov poj niam tshwj xeeb lub nra ntawm CKD.

Txo fertility hauv CKDyuav muaj ntau yam khoom siv thiab tej zaum yuav muaj feem cuam tshuam txog kev txo qis hauv zes qe menyuam, kev cuam tshuam cov tshuaj hormones, thiab kev siv tshuaj gonadotoxic ntxiv rau kev ua haujlwm ntawm kev sib deev thiab kev ua haujlwm. Fertility, kev ua haujlwm ntawm kev sib deev thiab kev ua ub no, thiab kev pheej hmoo ntawm kev sib deev kis tau nce ntxiv nrog kev hloov pauv. Kev xeeb tub yog ua tau ntawmtxhua theem ntawm CKD, txawm hais tias feem ntau nrog kev pheej hmoo siab ntawm niam thiab menyuam hauv plab. Kev tiv thaiv kab mob yog li qhov tseem ceeb hauv CKD, tab sis kev siv tsawg thiab cov kev pheej hmoo thiab cov txiaj ntsig ntawm ntau hom kev teeb tsa ntawm CKD tsis zoo. Txawm hais tias cov neeg mob CKD qhia txog kev noj qab haus huv ntawm kev yug me nyuam yog ib qho tseem ceeb ntawm kev saib xyuas, ntau tus kws kho mob nephrologists qhia txog qhov tsis muaj kev ntseeg siab thiab kev cob qhia hauv cheeb tsam no, qhia txog qhov xav tau rau kev tshawb fawb thiab kev kawm. Qhov tshwj xeeb kev saib xyuas kev noj qab haus huv ntawm cov menyuam yaus xav tau ntawm cov tub ntxhais hluas hloov pauv cov tub ntxhais hluas tuaj yeem ua rau muaj kev saib xyuas hauv kev cob qhia nephrology nrog ntau yam kev qhuab qhia. Qhov kev tshuaj xyuas no yuav tham txog poj niam kev noj qab haus huv thiab kev noj qab haus huv gynecological hauv cov tub ntxhais hluas thiabcov tub ntxhais hluas nrog CKDthaum tawm tswv yim kho mob thiab kev tshawb fawb cov tswv yim los txhim kho qhov no understudied tseem ceeb nam ntawm kev kho raum.

Nws yuav siv sij hawm ntev npaum li cas rau CISTANCHE ua haujlwm?

CovCKD ntau heevnyob rau hauv cov me nyuam yog tsis tu ncua, nrog antau dua qhov tshwm sim ntawm lub raum hloov khoHauv cov tub ntxhais hluas piv nrog rau lwm pawg hnub nyoog thoob ntiaj teb.1 Txawm hais tias feem ntau ua rau mob raum nyob rau hauv lub ntiaj teb no yog kub siab thiab ntshav qab zib, 2,3 tus me nyuam pib mob raum yog feem ntau vim yog congenital abnormality thiab hereditary disorders.4–7 Kev txo qis ntawm qhov tshwm sim ntawm qhov txawv txav ntawm lub raum thiab tso zis ntawm cov poj niam tuaj yeem pab piav qhia qhov qis qis ntawm CKD piv nrog cov txiv neej hauv cov tub ntxhais hluas.8 Tsis tas li ntawd, piv nrog cov neeg laus, glomerulonephritides yog qhov ua rau CKD ntau dua hauv cov menyuam yaus, tshwj xeeb tshaj yog nyob rau hauv cov tub ntxhais hluas cov hluas tom qab puberty.4,8

CKD nyob rau hauv cov poj niam cov pej xeem feem ntau nrog los ntawm txawv txav uterine los ntshav, kev sib deev dysfunction, txo fertility, thiab muaj kev pheej hmoo ntawm cev xeeb tub ntau dua.9,10 Feem ntau siv tshuaj tiv thaiv kab mob (xws li, cyclophosphamide, mycophenolate mofetil) rau autoimmune disorders, uas cuam tshuam rau poj niam glomerular. muaj qhov cuam tshuam tseem ceeb rau lub tsev menyuam los ntshav, fertility, thiab muaj peev xwm ua rau fetal malformations.11 Raws li North American Pediatric Renal Trials thiab Collaborative Studies database, cov tub ntxhais hluas sawv cev rau cov menyuam loj tshaj plaws raum hloov cov neeg txais kev pab.12 Txawm hais tias CKD muaj feem cuam tshuam nrog kev los ntshav uterine, 13- 15 lub raum hloov pauv, yam tsawg kawg hauv cov neeg laus, tuaj yeem rov los ntshav los ntawm lub tsev menyuam.15,16 raum hloov pauv cov txheej txheem17,18 cuam tshuam kev xeeb tub hauv cov poj niam thawj xyoo tom qab hloov pauv vim muaj kev pheej hmoo ntawm allograft rejection thiab cev xeeb tub cov teeb meem. Thaum kawg, cev xeeb tub nws tus kheej tuaj yeem muaj kev cuam tshuam thiab cuam tshuam rau lub raum ua haujlwm.19,20 Ua ke, ntau yam no qhia txog qhov tseem ceeb ntawm kev muab kev tu menyuam rau txhua tus poj niam nyob nrog CKD, suav nrog cov tub ntxhais hluas uas xav tau kev saib xyuas tus kheej thaum lub sijhawm no ntawm lub cev.

thiab kev hloov pauv kev sib raug zoo. Cov lus piav qhia no yuav nthuav dav cov ntsiab lus ntawm poj niam kev yug me nyuam thiab gynecological kev txiav txim siab hauv kev saib xyuas cov tub ntxhais hluas thiab cov tub ntxhais hluas cov neeg laus nrog CKD.

Cov txheej txheem

Txhawm rau muab cov ntsiab lus ntawm poj niam kev laus thiab kev noj qab haus huv ntawm poj niam cev xeeb tub ntawm cov tub ntxhais hluas nrog CKD, thawj tus kws sau ntawv (DHC) tau tshawb nrhiav 2 qhov chaw siv hluav taws xob, MEDLINE thiab Google Scholar. Cov ntsiab lus "kev noj qab haus huv ntawm menyuam yaus" lossis "gynecology" ua ke nrog "mob raum mob," "mob raum tsis txaus," "mob raum kawg," "mob raum tsis ua haujlwm," "dialysis," "hloov," thiab "nephrology" thiab lwm cov ntsiab lus cuam tshuam tau pab txheeb xyuas cov ntaub ntawv tseem ceeb. Cov ntsiab lus "contraception," "menstruation," "sexual dysfunction," thiab "tub hluas" ua ke nrog tib yam Kev Kho Mob Cov Ntsiab Lus kuj tau tshawb fawb hauv MEDLINE. Cov kev tshawb fawb no tau ua tiav los ntawm lub Tsib Hlis 2021. Cov npe siv los ntawm cov khoom siv tau raug tshawb nrhiav tes, thiab kev tshawb fawb tau ntxiv los ntawm cov ntsiab lus tseem ceeb los ntawm cov kws kho mob nephrologists nrog kev paub txog poj niam kev noj qab haus huv (SBA thiab SMD). Qhov tseem ceeb rau kev suav nrog hauv qhov kev tshuaj xyuas no tau muab rau thawj cov ntawv tshaj tawm cov ntaub ntawv qub (piv txwv li, kev soj ntsuam kev tshawb fawb raws li kev soj ntsuam randomized tsis muaj), cov txheej txheem kho mob, thiab kev tshuaj xyuas zoo.

Kab mob raum thiab Menstrual Cycle

Lub voj voog kev coj khaub ncaws suav nrog lub sijhawm ntawm thawj hnub ntawm lub tsev menyuam los ntshav mus rau thawj hnub tom ntej ntawm lub tsev menyuam los ntshav, 21 thiab kev coj khaub ncaws noj qab haus huv yuav siv sijhawm 24 txog 38 hnub nrog los ntshav tshwm sim # 8 hnub (qhov nruab nrab, 5 hnub). hais txog kev coj khaub ncaws noj qab nyob zoo tau piav qhia lwm qhov.21,23

Hauv CKD, kev cuam tshuam ntawm hypothalamic-pituitary-ovarian axis ua rau muaj qhov txawv txav ntawm kev ua me nyuam cov tshuaj hormones, qhov twg qhov kev cuam tshuam ntawm kev cuam tshuam nce nrog CKD kev loj hlob (Daim duab 1). Qhov kev cuam tshuam hormonal loj tshaj plaws, thiab feem ntau cov kev tshawb fawb tau ua nyob rau hauv cov pejxeem no.13,24 Hauv lub raum tsis ua haujlwm, lub pulsatile tso tawm ntawm gonadotropin-tso cov tshuaj hormones yog impaired, ua rau tsis muaj follicle-stimulating hormone thiab luteinizing hormone cyclicity.13 Yog li ntawd. Cov qib estradiol nyob qis qis, inhibiting surge thiab ovulation ntawm luteinizing hormone. Kev nce qib prolactin vim txo qis kev tshem tawm thiab nce kev tsim tawm kuj tseem ua rau kev tshem tawm.13,24,25 Ib qho ua tau ntawm cov tshuaj hormones txawv txav hauv lub raum tsis ua haujlwm yog tias cov qib prolactin siab tsis zoo rov qab mus rau hypothalamic-pituitary-ovarian axis thiab inhibit gonadotropin-tso tawm. hormonal secretion, yog li tiv thaiv gonadotropin tso tawm uas ua rau lub uterine los ntshav txawv txav.26–28 Hauv kev kawm yav tom ntej ntawm 57 tus poj niam hluas nrog theem 4 CKD thiab lub raum tsis ua haujlwm kho hemodialysis thiab peritoneal dialysis, 49% muaj hyperprolactinemia.29 Thaum muab piv nrog cov neeg koom nrog thiab tsis muaj. muaj kev cuam tshuam kev coj khaub ncaws, qib prolactin tau siab dua rau cov neeg muaj kev coj khaub ncaws.29

Kab mob raum thiab Hnub Nyoog Menarche

Menarche yog thawj qhov tshwm sim ntawm uterine los ntshav thiab pib ntawm poj niam kev yug me nyuam lifespan. Ntawm cov tub ntxhais hluas noj qab haus huv, lub hnub nyoog nruab nrab ntawm menarche yog kwv yees li 12 txog 13 xyoos.30,31 Ntau yam cuam tshuam nrog qhov pib ntawm menarche hauv cov pej xeem. Ib qho kev sib cuam tshuam ntawm lub cev qhov hnyav, 32-34 qhov siab, thiab qhov hnyav 35 nrog lub hnub nyoog ntawm menarche tau pom. Menarche yav dhau los tau tshaj tawm ntawm cov neeg nyob nrog lwm tus neeg uas tsis yog tsev neeg uas muaj 2 niam txiv lom neeg, 33,36-38 tab sis cov txiaj ntsig kev tshawb fawb sib txawv ntawm qhov cuam tshuam ntawm kev lag luam qis rau thaum ntxov 36,38,39 thiab late33 pib ntawm menarche. Cov neeg nyob hauv nroog thiab haiv neeg Dub tau cuam tshuam nrog kev mob khaub thuas ua ntej, txawm hais tias qhov sib txawv no yuav los yog tsis yog ib feem ntawm kev noj qab haus huv. , suav nrog kev pheej hmoo ntawm kab mob plawv, CKD, thiab kev tuag tag nrho.41–43

Daim duab 1. Hypothalamic-pituitary-ovarian axis nyob rau hauv cov poj niam uas muaj kab mob raum. Los ntawm Ahmed SB, Ramesh S. Kev sib deev cov tshuaj hormones hauv cov poj niam uas muaj mob raum. Nephrology Dialysis Transplantation, 2016, volume 31, issue 11, page 1787–1795 ª Tus Sau. Tshaj tawm los ntawm Oxford University Press sawv cev ntawm ERA-EDTA. All rights reserved.26 CKD, mob raum mob; FSH, follicle-stimulating hormone; GnRH, gonadotropin-tso cov tshuaj hormones; LH, luteinizing hormone.

Muab ntau yam cuam tshuam nrog qhov pib ntawm menarche, nws yog ib qho nyuaj rau elucidate lub koom haum, yog tias muaj, ntawm CKD thiab qhov pib los ntshav ntawm uterine. Hauv kev tshawb nrhiav yav tom ntej ntawm 57 tus poj niam hluas uas muaj theem 4 CKD thiab lub raum tsis ua haujlwm kho nrog hemodialysis thiab peritoneal dialysis, Serret-Montaya li al.29 tau tshaj tawm hnub nyoog nruab nrab ntawm menarche ntawm 12 xyoo tom qab tsis suav nrog cov neeg koom nrog thawj amenorrhea. Lub hauv paus ua rau CKD yog glomerulonephritis (22.8%) thiab congenital abnormality ntawm lub raum thiab urinary tract (22.8%), thiab feem ntau cov neeg koom muaj noj qab haus huv txoj kev noj qab haus huv. Txawm hais tias lub hnub nyoog nruab nrab ntawm menarche zoo sib xws rau cov neeg uas muaj thiab tsis muaj qhov txawv txav ntawm lub tsev menyuam, cov ntaub ntawv suav nrog kev kwv yees glomerular filtration rate, haiv neeg, thiab kev noj qab haus huv tsis tau tshaj tawm. Hauv kev tshawb nrhiav ntu ntu ntawm 287 tus ntxhais nrog CKD pib ua ntej menarche, lub hnub nyoog nruab nrab ntawm menarche yog 12 xyoo, txawm tias 10% tau ncua sijhawm menarche (txhais tias menarche ntawm $ 15 xyoo), uas cuam tshuam nrog African-Asmeskas haiv neeg, qis dua kwv yees. glomerular filtration rate, siv corticosteroid, thiab ntev CKD ntev, xaus lus qeeb menarche yuav qhia tau tias muaj kev pheej hmoo ntawm luv stature.44

Los ntawm kev xav ntawm nephrologists, paub txog lub hnub nyoog ntawm menarche yog ib qho tseem ceeb rau kev txiav txim siab raws li American Academy of Pediatrics tau hais tias kev coj khaub ncaws yog ib qho tseem ceeb hauv cov poj niam cov neeg mob.31 Txawm li cas los xij, hauv kev tshawb fawb ntawm 75 nephrologists (95% pediatric) , 5% neeg laus) xyaum nyob rau hauv lub tebchaws United States thiab Puerto Rico, Vasylyeva et al.45 qhia tias 17% yeej tsis / tsis tshua muaj ntaub ntawv lub hnub nyoog ntawm menarche ntawm cov tub ntxhais hluas cov neeg mob thiab ntau tshaj li ib feem peb yeej tsis / tsis tshua muaj ntaub ntawv hnub ntawm tus neeg mob lub cev xeeb tub zaum kawg. lub sij hawm. Qhov tsis sib xws no qhia txog qhov xav tau rau cov kws kho mob nephrologist kom ua tiav cov keeb kwm kev coj khaub ncaws, suav nrog lub hnub nyoog ntawm menarche, los txiav txim siab txog qhov kev sib deev tshwj xeeb hauv kev saib xyuas cov tub ntxhais hluas uas muaj kab mob raum.

Kab mob raum thiab Abnormal Uterine Bleeding

Abnormal uterine bleeding is defined as any disruption of a healthy menstrual cycle in terms of the volume of blood loss, duration, frequency, and regularity of menses.22 Abnormal uterine bleeding, particularly irregular or long ($40 days) menstrual cycles, has been associated with premature mortality in comparison to regular or short cycles in the general population.46 Abnormal uterine bleeding is also associated with absenteeism in school and work.47–49 In the general population of reproductive-aged women, the estimated prevalence of abnormal uterine bleeding is at least 10% to 30%,50 whereas heavy menstrual bleeding affects 30% of women throughout their reproductive lifespan.51 Heavy menstrual bleeding is defined as the loss of $80 ml of blood on each menstrual cycle, which is clinically indicated by 1 or more of the following factors: bleeding that lasts >7 days, bleeding that soaks through $1 menstrual product every hour for several hours, bleeding that requires simultaneous use of multiple menstrual products to manage flow, bleeding that requires a change of menstrual product during the night, or the presence of blood clots at least the size of a quarter.52,53 Abnormal duration of menses includes prolonged (>8 hnub) thiab luv luv (<3 days) uterine bleeding, whereas the abnormal frequency of menses includes infrequent (>38 hnub sib nrug) thiab nquag (<24 days apart) uterine bleeding.22 Absent uterine bleeding is defined by an absence of menses for 90 days, and irregular uterine bleeding is defined by variation in cycle length by $10 days.

Among adolescents in the general population, the prevalence of heavy, infrequent, and absent menstrual bleeding is reported as 34%, 20%, and 8%, respectively.54 Nevertheless, information on abnormal uterine bleeding is sparse in the adolescent CKD population. A prospective cohort study found that >50% ntawm cov ntxhais hluas uas muaj theem 4 CKD thiab lub raum tsis ua haujlwm tau kho nrog kev lim ntshav qhia txog qhov txawv txav ntawm lub tsev menyuam.29 Ntxiv mus, txawm tias 54% qhia txog kev coj khaub ncaws tsis tu ncua ntawm lub hauv paus, tsuas yog 47% qhia cov poj niam tsis tu ncua ib xyoos tom qab. Txawm li cas los xij, hauv cov poj niam laus premenopausal nrog CKD, qhov tshwm sim ntawm qhov txawv txav ntawm lub tsev menyuam los ntshav yog siab thiab ua rau muaj kab mob ntau ntxiv.13,14,24 Hauv kev tshawb fawb me me ntawm 17 tus poj niam hnub nyoog 18 txog 42 xyoo nrog raum tsis ua haujlwm kho nrog hemodialysis, Tsuas yog 1 tus poj niam tau tshaj tawm cov uterine los ntshav tsis tu ncua, thaum 6 tshaj tawm cov uterine los ntshav tsis tu ncua, thiab 10 tus poj niam tsis tuaj yeem los ntshav.13 Hauv kev tshawb fawb hla ntawm cov poj niam<55 years of age with kidney failure treated with hemodialysis and peritoneal dialysis,14 58% reported the absence of uterine bleeding. Furthermore, most of the menstruating women experienced irregular uterine bleeding, which was most often heavy menstrual bleeding. Abnormal uterine bleeding, especially heavy menstrual bleeding, is an important consideration in the CKD population, as potential implications include worsening anemia, increasing the need for erythropoietin-stimulating agents, and blood transfusions.24,55 This may be especially relevant for those in need of a kidney transplant, given the risk of sensitization. 24 A retrospective cohort study of 129 women with kidney failure (aged 41.6
14.2 years with follow-up for 9.5
10.2 years) treated with dialysis or kidney transplantation and followed by a gynecologist,15 78.7% had regular uterine bleeding before dialysis, though this decreased to 30.6% after dialysis initiation. The remaining participants reported infrequent (26%) or absent (43%) uterine bleeding after dialysis initiation.

Peb tsis paub txog tej yam kev kho mob tshwj xeeb rau cov uterine los ntshav uas txawv ntawm theem ntawm CKD. Txawm li cas los xij, kev kho mob rau qhov txawv txav ntawm lub tsev menyuam yuav tsum sib npaug nrog cov kev pheej hmoo ntawm cov neeg mob lub raum kev noj qab haus huv thiab kev soj ntsuam ntawm lawv cov comorbidities, contraindications, nyiam, thiab tsim nyog rau cov tub ntxhais hluas thiab cov hluas. Kev siv tshuaj hormones uas siv cov tshuaj progestin nkaus xwb lossis ua ke nrog cov tshuaj estrogen-progestin hormonal contraception tuaj yeem txhim kho lub tsev menyuam los ntshav ib ntus.56 Piv txwv li, nrog rau cov tshuaj progestin nkaus xwb intrauterine, txhaj tshuaj, thiab subdermal implants, qee cov neeg muaj kev tsis txaus los ntshav tom qab lub hlis mus rau ib xyoos. siv txawm tias thaum pib muaj qhov tsis xwm yeem thiab / lossis los ntshav hnyav.53,56–58 Cov tshuaj tiv thaiv kab mob sib xyaw ua ke ntawm qhov ncauj, thaj chaw hloov pauv, thiab lub nplhaib ntawm qhov chaw mos kuj tuaj yeem tswj cov ntshav, thiab yog siv tsis tu ncua yam tsis muaj tshuaj hormone-dawb lub lis piam (piv txwv li, ntev / txuas ntxiv-kho tawm. siv), lawv tuaj yeem tiv thaiv uterine los ntshav thiab cov tsos mob ntsig txog.57,59 Nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov, txawm li cas los xij, cov kev xaiv uas muaj estrogen ua rau muaj kev pheej hmoo ntawm thrombotic.59 Tranexamic acid, danazol therapy, gonadotropin-tso cov tshuaj hormone agonists, thiab nonsteroidal anti-inflammatory Cov tshuaj yog cov kev xaiv kho mob ntxiv, txawm tias muaj kev pheej hmoo thiab ncua sij hawm ntawm kev siv yuav tsum tau soj ntsuam kom zoo hauv cov ntsiab lus ntawm CKD, tshwj xeeb tshaj yog tom qab.56

Txawm hais tias qhov txawv txav ntawm lub tsev menyuam los ntshav yog muaj nyob rau hauv cov ntsiab lus ntawm cov kab mob raum, ib txoj kev tshawb fawb uas muaj cov kws kho mob nephrologists los ntawm Tebchaws Meskas thiab Puerto Rico tau tshaj tawm tias yuav luag 90% tsis muaj kev ntseeg siab / me ntsis kev ntseeg siab hauv kev tswj cov ntshav uterine txawv txav.45 Ntxiv rau, Hauv kev tshawb fawb ntawm cov neeg laus nephrologists los ntawm Tebchaws Meskas thiab Canada, ntau dua 65% ntawm cov neeg teb tau tshaj tawm tias tsis muaj kev ntseeg siab ntawm cov poj niam cov teeb meem kev noj qab haus huv, suav nrog kev ua poj niam cev xeeb tub, 60 tsuas yog 15% tau tshaj tawm tham txog kev coj khaub ncaws tsis zoo nrog lawv cov neeg mob.61 Cov kev tshawb pom no taw qhia qhov sib txawv ntawm kev paub txog kev saib xyuas gynecological ntawm cov poj niam cov neeg mob nrog CKD thiab qhia txog qhov xav tau ntawm cov kev kawm siv tau thiab kev cob qhia rau nephrologists hauv thaj chaw tseem ceeb ntawm kev saib xyuas neeg mob.

Kab mob raum thiab lub caij nyoog txom nyem

Kev txom nyem lub sij hawm yog txhais tau tias yog qhov tsis muaj kev paub txog kev los ntshav ntawm lub tsev menyuam thiab kev tsis muaj peev xwm nkag mus rau cov khoom coj khaub ncaws, 62 ua haujlwm rau kev noj qab haus huv, kev coj noj coj ua, thiab kev nom kev tswv. CKD muaj feem cuam tshuam nrog kev tsis sib haum xeeb tseem ceeb hauv zej zog, 63,64, thiab lub sijhawm kev txom nyem tsuas yog exacerbates kev lag luam ntawm CKD. Menarche thiab kev coj khaub ncaws yog qhov tseem ceeb ntawm kev noj qab haus huv ntawm poj niam hluas, 65 tab sis kev tsis muaj kev kawm thiab kev pab cuam ua rau muaj teeb meem nrog kev tswj hwm kev coj khaub ncaws, ua rau cov tub ntxhais hluas muaj kev thuam, kev txaj muag, kev ntshai, thiab kev ntxhov siab; rau qee qhov, muaj kev cuam tshuam ncaj qha rau kev kawm, kev noj qab haus huv, thiab kev noj qab haus huv.66 Lub sijhawm kev txom nyem ua rau qee cov tub ntxhais hluas ploj mus txog ib feem tsib ntawm lawv lub xyoo kawm ntawv.67 Ua ke nrog cov tsev kawm ntawv ploj mus rau kev teem sijhawm kho mob, cov tub ntxhais hluas uas muaj CKD yuav muaj kev pheej hmoo ntau dua. ntawm kev tsis tuaj kawm ntawv, ua rau muaj qib kev tuav pov hwm, kev kawm tsis tau tiav, thiab kev cuam tshuam ntawm kev kawm, txhua yam cuam tshuam rau lawv lub hlwb kev noj qab haus huv thiab lub neej zoo.68,69 Thaum kawg, txawm tias tsis muaj kev tshawb fawb tsom mus rau lub sijhawm txom nyem ntawm cov poj niam cev xeeb tub nrog CKD, txoj haujlwm kev lag luam hauv zej zog thiab cov nyiaj tau los hauv lub tebchaws kuj tseem yuav cuam tshuam rau ib qho kev nkag mus rau cov khoom noj khoom haus nyab xeeb thiab cov chaw tswj kev huv.63,64,70–72