Yuav Ua Li Cas Xaiv Txoj Kev Kho Mob Rau Membranous NephropathyⅡ

4. Txhawb kev kho mob membranous nephropathy

Txawm hais tias qib proteinuria, lub raum ua haujlwm, thiab qib NS, txhua tus neeg mob MN yuav tsum tau txais kev tswj hwm kev txhawb nqa zoo tshaj plaws thiab raug kho kom tsis txhob muaj teeb meem ntawm tus kab mob. Qhov kev kho no tuaj yeem txo qhov mob thiab kev tuag tsis muaj kev tiv thaiv kab mob.

Nyem rau Cistanche rau mob raum

Kev kho mob ntawm edema suav nrog kev siv cov tshuaj diuretics thiab kev txwv ntsev hauv kev noj haus. Kev kho thawj kab yog ob zaug-hnub voj diuretic. Vim tias kev tswj hwm ntev ntev ntawm furosemide tuaj yeem ua rau cov txheej txheem hloov kho, muaj pov thawj tias torsemide thiab bumetanide zoo dua. Yog tias muaj diuretic tsis kam, thiazide diuretic xws li chlorthalidone, hydrochlorothiazide, lossis metolazone tuaj yeem raug ntxiv los tiv thaiv distal nephron sodium reabsorption. Thaum siv cov tshuaj diuretic no, distal sodium reabsorption tuaj yeem txo qis los ntawm kev noj thiazide diuretic 2 mus rau 5 teev ua ntej lub voj diuretic. Amiloride thiab acetazolamide tuaj yeem siv los kho hypokalemia thiab metabolic alkalosis, raws li. Vim tias kev nqus ntawm plab hnyuv ntawm cov diuretics tuaj yeem cuam tshuam los ntawm cov hnyuv phab ntsa edema, cov hlab ntsha diuretics tuaj yeem yog qhov kev xaiv zoo. Intravenous albumin tuaj yeem pab txhim kho lub hom phiaj nephron xa cov tshuaj diuretics thiab yuav tsum tau txiav txim siab yog tias cov ntshav albumin tsawg dua 2.0 g/dL. Kev noj tshuaj sodium txhua hnub yuav tsum tsis pub tshaj 2 g lossis 88 mEq, thiab kev txwv cov dej tsis tsim nyog tshwj tsis yog tias hyponatremia lossis dej ntau dhau tshwm sim.

Angiotensin-hloov enzyme inhibitors (ACEi) lossis angiotensin II receptor blockers (ARBs) yog thawj kab kev kho mob rau kev tswj ntshav siab vim tias lawv muaj peev xwm txo cov proteinuria. Ua kom tiav lub hom phiaj ntshav siab (ie, systolic ntshav siab<120 mmHg) can both prevent cardiovascular risk and slow the decline in GFR. On the other hand, if proteinuria is reduced to less than 0.5 grams per day or to less than 1.5 grams per day, loss of kidney function can be prevented. Furthermore, the reduction in proteinuria and the subsequent increase in serum protein and albumin levels may prevent infectious, metabolic, and thromboembolic risks. ACEi and ARBs can reduce proteinuria by 50%. These drugs should be administered at the maximum tolerated dose and should be discontinued only if the creatinine increases by more than 30%, the loss of renal function continues, or the induced hyperkalemia is no longer refractory to any available medical therapy. If this is the case, a direct renin inhibitor (DRI) or mineralocorticoid receptor antagonist (MRA) can be used instead of, but in addition to, ACEi or ARBs. Finally, non-dihydropyridine calcium channel blockers (CCBs) can also reduce proteinuria, although rarely.

Hyperlipidemia yuav tsum tau kho yog tias tus neeg mob muaj lwm yam kev pheej hmoo rau cov kab mob plawv, suav nrog ntshav qab zib, haus luam yeeb, kub siab, lossis rog dhau. Thawj kauj ruam hauv kev kho dyslipidemia yog kev noj zaub mov thiab kev ua neej hloov pauv. Cov tshuaj statin atorvastatin, piv nrog rosuvastatin, tuaj yeem txo cov proteinuria. Tam sim no, muaj cov ntaub ntawv tsis txaus rau kev siv ntau ntawm kev kho mob thib ob xws li ezetimibe lossis PCSK9 inhibitors.

Ntawm cov qauv sib txawv ntawm glomerulonephritis, MN yog qhov txaus ntshai tshaj plaws rau cov xwm txheej thromboembolic, tshwj xeeb tshaj yog cov hlab ntsha sib sib zog nqus thiab lub raum vein thrombosis, thiab qhov kev pheej hmoo siab dua nyob ntawm qib proteinuria thiab albumin qib qis dua 2.5 g / L. Yog tias qhov tshwm sim thromboembolic tau tshwm sim, ua kom tiav anticoagulation yog tsim nyog. Ntawm qhov tod tes, prophylactic anticoagulation yuav tsum tau ua tib zoo soj ntsuam kom coj mus rau hauv tus account qhov txaus ntshai ntawm los ntshav thiab thromboembolism. Kev kho thawj kab yog heparin (los yog nws cov derivatives) lossis warfarin; Kev kawm ntxiv txog lub luag haujlwm ntawm cov tshuaj tiv thaiv qhov ncauj ncaj qha yog xav tau. Aspirin tuaj yeem siv rau cov neeg mob uas muaj qib albumin tsawg dua 2.5 g / L uas muaj kev pheej hmoo siab rau venous thromboembolism thiab cov uas muaj kev pheej hmoo los ntshav (ua rau muaj kev cuam tshuam rau kev siv warfarin), xws li hauv cov neeg mob uas muaj kev pheej hmoo rau arterial thromboembolism.

5. Keeb kwm ntawm kev tiv thaiv kab mob rau membranous nephropathy

Cov tshuaj thawj zaug siv los kho MN yog glucocorticoids nkaus xwb, txawm hais tias kev sim nrog prednisone tsis pom lossis tsuas muaj txiaj ntsig zoo. Tsis tas li ntawd, ib qho kev sim uas muaj cyclophosphamide ua tsis tau zoo los qhia txog kev txhim kho hauv cov proteinuria lossis lub raum ua haujlwm, thiab cov kev tshawb fawb rov qab suav nrog nitrogen mustard tau xav tias nws yuav cuam tshuam txog kev mob qog noj ntshav.

Xyoo 1984, ntau qhov chaw Italian randomized tswj kev sim faib 67 tus neeg mob nrog MN rau hauv kev kho mob lossis hloov pauv nitrogen mustard thiab glucocorticoids rau 6 lub hlis. Methylprednisolone 1 g intravenously rau 3 hnub thiab 0.5 mg/kg prednisolone qhov ncauj rau 27 hnub ntawm 1, 3, thiab 5 lub hlis, thiab nitrogen mustard ntawm 2, 4, thiab 6 lub hlis 0.2 mg/kg/hnub. Cov pab pawg kho mob muaj lub raum ua haujlwm ruaj khov thiab txhim kho cov proteinuria, thiab cov txiaj ntsig tau lees paub 10 xyoo tom qab. Txoj hauv kev no, tseem hu ua "Protocollo-Ponticelli," zoo dua li glucocorticoids ib leeg. Hauv xyoo 1998, cov txiaj ntsig ntawm kev sim tsim los ua kom pom tias cyclophosphamide tsis yog qhov qis dua rau nitrogen mustard hauv kev hloov kho kho tau raug luam tawm; Cov neeg mob kho nrog yav dhau los tau zoo dua ua tiav thiab ib nrab kev tso tawm tus nqi, txo qis tus nqi rov qab, thiab zoo li yog cov tshuaj tiv thaiv zoo. Txij thaum ntawd los, cyclophosphamide tau hloov nitrogen mustard nrog "hloov Ponticelli" mus kom ze.

Cov lus qhia ntxov rau lub luag haujlwm muaj peev xwm ntawm cyclosporine hauv kev kho mob ntawm MN yog los ntawm kev soj ntsuam kev tshawb fawb uas cov neeg mob ua tiav cov lus teb ib nrab lossis ua tiav. Txawm li cas los xij, qhov kev xaiv kho mob no cuam tshuam los ntawm kev rov ua dua tom qab siv tshuaj txo qis lossis tsis txuas ntxiv thiab muaj peev xwm nephrotoxicity. Tom qab ntawd, ob txoj kev tshawb fawb randomized tau pom tias muaj kev txhim kho hauv kev txo qis hauv lub raum kev ua haujlwm thiab proteinuria hauv pawg prednisone piv nrog cov placebo, thiab ntau dua ntawm kev tso tawm hauv pawg prednisone piv nrog cov placebo ntxiv rau prednisone. zoo. Zoo ib yam li cyclosporine, tacrolimus kuj muaj txiaj ntsig zoo tab sis muaj qhov rov ua dua dua tom qab txiav tawm. Cov ntaub ntawv yog los ntawm kev tshawb fawb rov qab, kev tshawb fawb txog kev cuam tshuam [thiab kev tshawb fawb randomized]. Thaum tacrolimus tau koom ua ke nrog corticosteroids, 24 lub hlis ntawm kev kho mob ua rau cov txiaj ntsig zoo dua nyob rau hauv cov nqe lus ntawm kev tshem tawm thiab rov qab ua dua piv nrog 12 lub hlis ntawm kev kho mob. Lwm cov tshuaj uas tau thov yog mycophenolate mofetil (MMF), txawm hais tias MMF muaj kev pheej hmoo siab dua ntawm kev rov qab los piv nrog cyclophosphamide thiab, thaum siv ua ke nrog corticosteroids, tsis zoo dua li cyclophosphamide. Cov lus teb ib nrab kuj tseem qis dua. Nco ntsoov, tsis muaj qhov sib txawv ntawm kev txo cov proteinuria lossis tshem tawm ntawm kev siv MMF thiab kev txhawb nqa ib leeg.

6. KDIGO 2021 Kev kho mob membranous nephropathy

Vim tias cov neeg mob MN tuaj yeem ua rau muaj kev zam txim tsis tu ncua, nws yog ib qho tseem ceeb los txiav txim siab seb cov neeg mob twg yuav tau txais txiaj ntsig ntau dua los ntawm kev siv tshuaj tiv thaiv kab mob thiab cov neeg mob twg tuaj yeem kho tau nrog kev txhawb nqa. Yog li, cov lus qhia tshiab KDIGO pom zoo kom ntsuas qhov kev pheej hmoo ntawm lub raum tsis ua haujlwm los ntawm kev faib cov neeg mob mus rau hauv qis, nruab nrab, siab, thiab muaj kev pheej hmoo siab kawg rau cov kab mob hauv lub raum subgroups, suav nrog kev soj ntsuam thiab kuaj cov qauv.

Yog li ntawd, vim tias qhov kev tso tawm tsis tu ncua tuaj yeem tshwm sim, nws raug nquahu kom tos 6 lub hlis thaum siv cov tshuaj tua kab mob siab tshaj plaws proteinuria. Ntawm qhov tod tes, yog tias muaj proteinuria siab, qib siab ntawm PLA2R autoantibodies, lossis qis molecular yuag proteinuria tam sim no, yuav tsum tau rov ntsuam xyuas ntxov. Hauv qhov sib piv, yog tias lub raum ua haujlwm poob qis sai thiab nephrotic syndrome tsis teb rau cov tsos mob, kev tiv thaiv ntxov ntxov yuav tsum tau pib kho sai li sai tau. Cov neeg mob uas muaj tsawg dua 4 g / d muaj tus nqi siab dua ntawm kev tshem tawm tus kheej piv nrog cov neeg mob uas muaj tsawg dua 8 g / d thiab 12 g / d (45% vs. 34 vs. 25-40%, feem) thiab tau txuam nrog siab. Qib ntawm cov tshuaj tiv thaiv Piv nrog PLA2R cov tshuaj tiv thaiv, cov neeg mob uas tsis tshua muaj cov tshuaj tiv thaiv PLA2R cov tshuaj tiv thaiv muaj feem ntau dua ntawm kev tshem tawm tus kheej. Tsis tas li ntawd, ntxiv rau qhov muaj nuj nqis ntawm cov lej, cov kab ke ntawm cov kev txwv no kuj yuav tsum tau ntsuas.

Yog li ntawd, txoj kev kho immunosuppressive yuav tsum tau siv tsuas yog hauv cov neeg mob uas muaj kev pheej hmoo rau mob raum mob hnyav. Yog hais tias cov proteinuria tsis nyob rau hauv cov nephrotic ntau yam (xws li, tsawg dua 3.5 g / hnub), yog tias cov ntshav albumin ntau dua 30 g / L, thiab eGFR ntau dua 60 ml / min, nws tsis tas yuav tsum tau. Cov neeg mob no feem ntau muaj kev pheej hmoo tsawg ntawm cov teeb meem thromboembolic thiab muaj ob peb lossis tsis muaj tsos mob thiab yog li tsuas yog kho tau zoo. Immunosuppressive therapy yog txuam nrog kev pheej hmoo ntxiv rau cov neeg mob zoo li no yam tsis muaj txiaj ntsig zoo. Ntawm qhov tod tes, yog tias muaj tsawg kawg yog ib qho kev pheej hmoo rau kev kis kab mob, kev siv tshuaj tiv thaiv kab mob tau pom zoo. Kev xaiv ntawm ib qho kev kho mob tshwj xeeb yuav tsum coj mus rau hauv tus neeg mob tus yam ntxwv, muaj tshuaj, tus neeg mob thiab tus kws kho mob nyiam, thiab cov kev mob tshwm sim tshwj xeeb ntawm txhua yam tshuaj.

Txij li thaum KDIGO 2012 tsis txhawb nqa daim ntawv thov MMF, kev siv MMF tsis suav nrog. Ntau qhov kev sim tshuaj ntsuam xyuas (RCTs) thiab cov kev tshawb fawb sib koom ua ke tau ua pov thawj tias rituximab (RTX) thiab tacrolimus / cyclosporine tuaj yeem txhim kho qhov ua tiav cov lus teb thiab cov lus teb ib nrab, thiab lawv cov ntaub ntawv kev nyab xeeb zoo dua li ntawm cyclophosphamide. Txawm li cas los xij, kev siv calcineurin inhibitors (CNIs) yog cuam tshuam los ntawm lawv cov kev rov qab ua haujlwm siab thiab, yog li ntawd, lawv tsuas yog siv tau ua monotherapy thaum muaj kev pheej hmoo ntawm kev loj hlob. Cyclophosphamide (CYC), ntawm qhov tod tes, txo qhov kev pheej hmoo ntawm lub raum tsis ua haujlwm ntau dua tab sis yuav tsum siv rau cov neeg mob uas muaj kev pheej hmoo siab vim nws lub nra hnyav. Cov koob tshuaj ntawm cov tom kawg yuav tsum tsis pub tshaj 36 g kom tsis txhob muaj malignancy lossis 10 g kom khaws cia fertility.

Lub ntsiab txhais ntawm kev rov tshwm sim MN txawv ntawm cov kws sau ntawv. Qee tus kws sau ntawv txhais tau tias rov qab ua dua li qhov nce hauv cov proteinuria ntau dua 3.5 g / d, thiab KDIGO 2021 pawg neeg ua haujlwm txhais tau tias rov qab ua dua li qhov nce hauv proteinuria nrog kev txo qis hauv cov ntshav albumin. Yog tias tus neeg mob rov qab ua dua tom qab thawj chav kawm ntawm rituximab, ib chav kawm thib ob ntawm cov tshuaj siv tau. Ntawm qhov tod tes, yog tias rov tshwm sim tom qab ib chav kawm ntawm CNI + steroid therapy, rituximab tuaj yeem siv ib leeg lossis ua ke nrog CNI kho. Thaum kawg, yog tias thawj kab kev kho mob muaj xws li cyclophosphamide + glucocorticoids, tib lub sijhawm tuaj yeem rov ua dua rau chav kawm thib ob, suav nrog cov koob tshuaj siab tshaj plaws lossis CNI + rituximab lossis rituximab ib leeg tuaj yeem siv los ua kev kho thib ob.

Ntawm qhov tod tes, tsis muaj kev pom zoo rau qhov tseeb txhais ntawm cov kab mob resistant. Yog tias cov tshuaj tiv thaiv PLA2R tau kuaj pom ua ntej kev kho thawj kab, kab mob uas cov tshuaj tiv thaiv kab mob titers nyob siab tom qab ib qho kev kho mob tuaj yeem txhais tau tias tiv taus. Hauv qhov sib piv, kev ntsuam xyuas proteinuria tsis tuaj yeem siv vim tias nws tuaj yeem kav ntev txog 24 lub hlis tom qab kho. Yog tias tus neeg mob PLA2R tsis zoo, qhov mob nephrotic tsis tu ncua tuaj yeem txhais tau tias tiv taus. Thaum ntsuas tus kab mob tiv thaiv, thawj kauj ruam yog kuaj xyuas kev ua raws li kev kho mob los ntawm kev ntsuas B hlwb, tshuaj tiv thaiv rituximab antibodies, CNI, thiab IgG qib lossis kev loj hlob ntawm leukopenia hauv cov neeg mob noj cyclophosphamide.

Yog tias thawj kab kev kho mob suav nrog RTX thiab eGFR ruaj khov, kev kho CNI tuaj yeem ntxiv. Cyclophosphamide + glucocorticoids tuaj yeem ua tau yog tias eGFR txo qis lossis CNI + RTX tsis tuaj yeem ua tiav cov txiaj ntsig kho mob, cyclophosphamide + glucocorticoids tuaj yeem ua tau. Ntawm qhov tod tes, yog tias CNI tau sim thawj zaug, RTX tuaj yeem muab tau yog tias lub raum ua haujlwm ruaj khov; Txawm li cas los xij, yog tias tsis ruaj khov lossis RTX tsis ua tiav cov lus teb, tus neeg sawv cev alkylating yuav tsum tau sim. Yog tias tom kawg yog siv los ua thawj kab kev kho mob, RTX tuaj yeem ntxiv ua ntej sim lwm yam ntawm cov neeg ua haujlwm alkylating. Yog tias cov neeg mob tsis teb rau RTX lossis CYC, lawv yuav raug qhia kom koom nrog kev sim tshuaj (saib "Kev kho tshiab rau membranous nephropathy" hauv qab no).

Cistanche kho mob raum li cas?

Cistancheyog ib hom tshuaj suav tshuaj ntsuab siv rau ntau pua xyoo los kho ntau yam mob, suav nrograumkab mob. Nws yog muab los ntawm cov stems qhuav ntawm Cistanche deserticola, ib tsob nroj nyob rau hauv cov suab puam ntawm Tuam Tshoj thiab Mongolia. Lub ntsiab active Cheebtsam ntawm cistanche yogphenylethanoidglycosides, echinacoside cov tshuaj, thiabacteoside, uas tau pom tias muaj txiaj ntsig zoo rau lub raum kev noj qab haus huv.

Kab mob raum, tseem hu ua kab mob raum, hais txog ib yam mob uas lub raum ua haujlwm tsis zoo. Qhov no tuaj yeem ua rau muaj cov khoom pov tseg thiab cov co toxins hauv lub cev, ua rau muaj ntau yam tsos mob thiab teeb meem. Cistanche tuaj yeem pab kho mob raum ase los ntawm ntau lub tswv yim.

Ua ntej, cistanche tau pom tias muaj cov nyhuv diuretic, txhais tau tias nws tuaj yeem ua rau cov zis ntau ntxiv thiab pab tshem tawm cov khoom pov tseg ntawm lub cev. Qhov no tuaj yeem pab txo lub nra ntawm lub raum thiab tiv thaiv kev tsim cov co toxins. Los ntawm kev txhawb nqa diuresis, cistanche kuj tseem tuaj yeem pab txo qis ntshav siab, ib qho teeb meem ntawm cov kab mob raum.

Ntxiv mus, cistanche tau pom tias muaj cov teebmeem antioxidant. Kev ntxhov siab oxidative, tshwm sim los ntawm qhov tsis sib xws ntawm kev tsim cov dawb radicals thiab lub cev tiv thaiv antioxidant, ua lub luag haujlwm tseem ceeb hauv kev mob raum. ies pab neutralize dawb radicals thiab txo Oxidative kev nyuaj siab, yog li tiv thaiv lub raum los ntawm kev puas tsuaj. Cov phenylethanoid glycosides pom hauv cistanche tau tshwj xeeb hauv kev tshem tawm cov dawb radicals thiab inhibiting lipid peroxidation.

Tsis tas li ntawd, cistanche tau pom tias muaj cov nyhuv anti-inflammatory. Kev mob yog lwm yam tseem ceeb hauv kev loj hlob thiab kev loj hlob ntawm cov kab mob raum. Cistanche's anti-inflammatory zog pab txo cov zus tau tej cov pro-inflammatory cytokines thiab inhibit qhov ua kom o yuav tsum tau txoj kev, yog li alleviating o nyob rau hauv lub raum.

Tsis tas li ntawd, cistanche tau pom tias muaj cov teebmeem immunomodulatory. Hauv kab mob raum, lub cev tiv thaiv kab mob tuaj yeem ua rau tsis zoo, ua rau muaj kev mob ntau dhau thiab cov ntaub so ntswg puas. Cistanche pab tswj lub cev tiv thaiv kab mob los ntawm kev hloov kho kev tsim khoom thiab kev ua haujlwm ntawm lub cev tiv thaiv kab mob, xws li T hlwb thiab macrophages. Txoj cai tiv thaiv kab mob no pab txo qhov mob thiab tiv thaiv kev puas tsuaj ntxiv rau lub raum.

Ntxiv mus, cistanche tau pom los txhim kho lub raum kev ua haujlwm los ntawm kev txhawb nqa kev tsim kho ntawm lub raum hlab nrog cov hlwb. Lub raum tubular epithelial hlwb ua lub luag haujlwm tseem ceeb hauv kev pom thiab rov nqus cov khoom pov tseg thiab electrolytes. Hauv kab mob raum, cov hlwb no tuaj yeem raug puas tsuaj, ua rau lub raum ua haujlwm puas. Cistanche lub peev xwm los txhawb kev tsim kho ntawm cov hlwb no pab kho lub raum kom zoo thiab txhim kho lub raum tag nrho.

Ntxiv nrog rau cov kev cuam tshuam ncaj qha rau lub raum, cistanche tau pom tias muaj txiaj ntsig zoo rau lwm yam kabmob thiab lub cev hauv lub cev. Txoj hauv kev zoo rau kev noj qab haus huv no tseem ceeb tshwj xeeb hauv cov kab mob raum, vim tias tus mob feem ntau cuam tshuam rau ntau lub cev thiab lub cev. che tau pom tias muaj kev tiv thaiv rau lub siab, lub plawv, thiab cov hlab ntsha, uas feem ntau cuam tshuam los ntawm kab mob raum. Los ntawm kev txhawb nqa kev noj qab haus huv ntawm cov kabmob no, cistanche pab txhim kho lub raum tag nrho thiab tiv thaiv kev mob ntxiv.

Hauv kev xaus, cistanche yog cov tshuaj suav tshuaj ntsuab siv rau ntau pua xyoo los kho mob raum. Nws cov active Cheebtsam muaj diuretic, antioxidant, anti-inflammatory, immunomodulatory, thiab regenerative teebmeem, uas pab txhim kho lub raum ua haujlwm thiab tiv thaiv ob lub raum los ntawm kev puas tsuaj ntxiv. , cistanche muaj txiaj ntsig zoo rau lwm yam kabmob thiab lub cev, ua rau nws txoj hauv kev zoo rau kev kho mob raum.