| Objective:Diabetic nephropathy (DN) is a common chronic complications of diabetes ,when DN developed toâ…£,â…¤period, and nephrotic syndrome in particular, which classified by "substantial proteinuria, hypoproteinemia and a high degree of edema", intractable heart failure is usually combined. To DN with intractable heart failure patients, drug treatment is ineffective, and the mortality is high, the treatment is difficult. In this study, According to diabetes; DN; intractable heart failure diagnostic criteria and the New York Heart Association (NYHA) heart function classification standards, we strictly screen DN with intractable heart failure (Left heart failure, heart functionâ…£level) patients (15 cases), nine cases of male, six cases of female, the oldest is 63 years old and the youngest is 44-year-old, the average age is 52.1. Plus blood purification treatment to the disease. We investigate the pathophysiological mechanisms and evaluate the effection of blood purification treatment.Treatment:1. At first, femoral vein or internal jugular vein intubation, the establishment of vascular access.2. Use heparin, the first agent is 0.8 mg / kg, intravenous injection foe 10 minutes before the start of hemodialysis, then artery-added 8 mg every one hour.3. Add RBC suspension 200 ml, albumin 10-20 g when the first hemodialysis. (Add 20 g albumin, when serum albumin below 20 g/L).4. Dehydrated 3 Kg when the first hemodialysis. The two or three days dialysis, four hours each, According to facial; leg edema and pulmonary moist rale, dehydrate 3-5 Kg, weigh body weight after each dialysis.5. When edema and pulmonary moist rale are disappeared, then dry weight is determined. Inform patients to control diet, blood dialysis three times a week, each four hours.To reduce the amount of urine, the weight of dehydration should be higher than dry weight.6. The basis of the treatment include: anti-infection, control blood sugar (insulin therapy to strengthen), blood lipids, blood pressure, cardiotonic drug,blood supplementary materials and the use of erythropoietin, and so on.Observations:1. After the first hemodialysis, respiratory symptom is significantly eased, pulmonary moist rale is decreased significantly. Heart rate and respiratory rate are decreased significantly,which has significant statistically difference (P<0.01). Oxygen saturation significantly higher than pre-dialysis, which also has significant difference (P <0.01).2. After two or three hemodialysis, compared with pre-dialysis, potassium, sodium, chlorine, carbon dioxide combination are improved, the difference is significant.3. The amout of serum albumin and protein value after 14 days's hemodialysis are higher than four days after hemodialysis (P <0.01), the difference was statistically significant.4. Two weeks later, edema and dyspnea are completely disappeared, chest film review show that pleural effusion is completely disappeared. Two cases of patients with cardiac functionâ… -class, six cases of patients with cardiac functionâ…¡, seven cases of patients with cardiac function gradeâ…¢.Discussion:We investgated the linkage of DN and refractary heart failure, a combination of factors contributed to the occurrence of disease and development, but hypoproteinemia caused by DN is the the main cause. First of all, hypoproteinemia may increase pulmonary edema, lung diffusion function decreased. Secondly, with the gradual decrease of serum albumin, the plasma colloid osmotic pressure become lower and lower.which lead to a high degree of edema and reductant of blood circulation, thereby enabling cardiac output decline. And nephrotic syndrome patients with gastrointestinal mucosal edema lead to anorexia, inadequate protein intake, poor absorption will further increase the hypoproteinemia. In addition,when toxic substances is accumulated (such as methyl guanidine), bone marrow function is inhibited, the edema of gastrointestinal tract will decrease the intake of the iron and protein, so the original anemia is aggravated, heart failure continue progressing. Dysfunction of lung would lead to myocardial ischemia, the accumulation of lactic acid, lower of high-energy phosphate bond, which will damage heart and accelerate the deterioration of heart failure. Cardiac output decrease led to kidney inadequate blood perfusion, patients are not sensitive to diuretics, and large doses of diuretics precisely will lead to electrolyte imbalance, acid-base disorders and kidney function deterioration. On the one hand, electrolyte imbalance often complicated by the arrhythmia, toxic accumulation injury myocard, metabolic acidosis inhibit myocardial contraction, heart failure deterioration will continue. On the other hand, because of imbalance of inner environment, drug effect can not play, heart failure is difficult to be corrected.A combination of factors for the occurrence and development of the disease. The key issues of treatment is how to remove of metabolic poison; edema, and how to correct hypoproteinemia, anemia and electrolyte imbalance and acid-base disorders, This's the only way to win time and opportunity for further treatment. Blood purification technology has the advantage of being: not only can remove metabolic poison, maintain acid-base balance and electrolyte balance, and dehydration in the same time added albumin can reduce the hypoproteinemia, but also avoid the adverse effects caused by the sudden loss of blood volum. We can control the amount of dehydration,so we can reduce the urine, then the loss of protein is solved. In addition, hemodialysis can eliminate the increase of blood renin; angiotensin-aldosterone, and other substances, control the adverse effects of these substances, which can activate neuroendocrine. We stressed the role of blood purification, at the same time, we pay attention to anti-infection, control blood sugar (insulin therapy to strengthen), blood lipids, blood pressure, cardiatonic drugs, blood supplementary materials and the use of erythropoietin, and other basic treatment.The fundamental aim of renal replacement therapy is to extend life; improve the quality of life, and to promote rehabilitation and return to society. Choose hemodialysis at the right time can reduce complications and mortality, Screen creatinine clearance (Ccr) as a indicator of hemodialysis, when the value of Ccr is 10-15ml/min, dialysis can increase the long-term survival rate, if Ccr <5ml/min, complications of uremia are obvious, so hemodialysis can not prevent these complications progressing. Creatinine is a product of muscle metabolism, and the total is closely related to the amout of muscle,which is up to age, sex, nutritional status. The synthesis of protein decreased in DM patients, and muscle volume decreased, so serum creatinine level often do not accurately reflect the severity of the disease. What time to hemodialysis can not rely entirely on the level of Scr. Compared with non-diabetic nephropathy (NDN) patients, DN patients have more coronary heart disease and heart failure, cardiac and renal complications are not parallel to the extent of damage, the time of dialysis in DN patients should be earlier than that in the NDN patients. When it is difficult to correct the excessive capacity or pulmonary edema with diuretics,we should also start with hemodialysis treatment. Thus, DM secondary nephrotic syndrome with intractable heart failure patients should be comprehensive analysed, objectively evaluated, and add blood purification treatment timingly.Because of the limited number of patients, the results will have a certain inevitable limitations. Failure to follow-up study, we can not determine the long-term prognosis. Therefore, this needs further study.Conclusion:1. Blood purification can remove metabolic poison and reduce edema of gastrointestinal tract,then improve the nutritional status of patients. Dehydration can control the loss of protein, thus fundamentally solve the hypoproteinemia.2. Plus blood purification to treat diabetic kidney syndrome secondary intractable heart failure patients, which is safe and effective.
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