A few days ago, a friend called me and said that his nephew Xiao Wang was only in his 20s, had nephrotic syndrome, and when he came to the hospital for follow-up, he suddenly fell to the ground.
After the doctor received the diagnosis, the diagnosis was pulmonary embolism, fortunately occurred in the hospital, and the rescue was timely, and finally saved a life.
Remembering the thrilling scene of that day, my friend still feels afraid.
Yes, a kidney disease, the scourge of the kidney is not enough, how to run to the lungs to toss it?
Image source: Stand Cool Helo
First, walking suddenly fell to the ground, 20-something boys suffered from "silent killer" pulmonary embolism
Many people, like my friends, may not understand why a strong guy in his 20s suddenly fell to the ground because of a pulmonary embolism.
What is more curious is why kidney disease occurs pulmonary embolism?
In fact, this is not unusual in nephrology, sometimes it is often encountered, for example, last year, we treated 3 cases of pulmonary embolism, 2 of which are young men in their 30s.
Every time it is encountered, it is an urgent rescue.
A few days ago, it was also reported that a veteran in his 20s, who turned out to be in particularly good health, was also because of nephrotic syndrome and pulmonary embolism rescue.
Talking about this, let me first talk about what pulmonary embolism is.
Pulmonary embolism, also known as pulmonary artery embolism, is a pulmonary circulation obstruction caused by "impurities" in the blood (most commonly thrombuses) blocking pulmonary arteries.
The outcome of blocked pulmonary arteries is not pulmonary ischemia, but generalized hypoxia.
The circulatory system of the human body is composed of a systemic circulation (large circulation) system and a pulmonary circulation (small circulation) system, peripheral blood flows back to the right heart through the veins, right heart blood shoots into the pulmonary artery, in the lungs, the blood releases carbon dioxide, and fully combines with oxygen, and then oxygenated blood flows back through the pulmonary vein to the left heart, and the left heart is then shot into the aortic to supply the whole body tissue, so as to complete a circulation.
However, if a pulmonary embolism occurs and the right heart is blocked from shooting blood into the lungs, the blood cannot release carbon dioxide, nor can it combine with oxygen, and the whole body is hypoxic, and the patient often dies due to lack of oxygen.
Therefore, pulmonary circulation is small but critical; pulmonary embolism, although small, is often fatal.
Second, the onset of pulmonary embolism is more dangerous than acute myocardial infarction
Pulmonary embolism, which is mainly manifested by symptoms such as dyspnea, severe chest pain, hemoptysis, and fever, especially like acute myocardial infarction.
According to statistics, the mortality rate of pulmonary embolism without treatment is 20% to 30%, and the mortality rate of those with a clear diagnosis and treatment is reduced to 2% to 8%. In the United States, the mortality rate of pulmonary embolism is second only to tumors and myocardial infarction [1].
According to statistics, 75% to 90% of pulmonary embolism embolism comes from deep vein thrombosis of the lower limbs, and the thrombus returns to the right heart with venous blood, and then is shot into the pulmonary artery, thereby blocking the pulmonary artery to form a pulmonary embolism.
Let's start with the human blood system.
Human blood has a coagulation system and an anticoagulant system. Normally, blood is in a non-coagulated state because anticoagulants play a role.
In the case of skin incredulities or rupture of blood vessels, the blood will automatically coagulate, which is the coagulation factor at work.
So, under normal circumstances, coagulation and anticoagulation are always in a dynamic equilibrium, but once the disease occurs, this balance is broken, such as nephrotic syndrome, causing pulmonary embolism.
3. Why does nephrotic syndrome cause pulmonary embolism?
Friends told me that although Xiao Wang was only in his 20s, after suffering from nephrotic syndrome, his legs were swollen badly and he was listless all day.
Nephrotic syndrome, in fact, is a variety of reasons leading to damage to the filtration membrane of the kidneys, a large number of proteins in the blood leak through the damaged filtration membrane into the urine and loss from the urine, resulting in a large number of proteinuria, hypoproteinemia, edema and hyperlipidemia.
In addition to the loss of plasma albumin, a large amount of protein is also lost, such as various hormones such as insulin and thyroxine, which also include coagulation factors and anticoagulants (both of which are also proteins).
However, the molecular weight of the anticoagulant factor is small, and it is easier to lose through the damaged filtration membrane, while the molecular weight of the coagulation factor is large and the loss is less, so the clotting factor in the blood prevails, and the blood is in a hypercoagulable state.
In addition, nephrotic syndrome will have low protein edema, water from the blood vessels "leak" to the outside of the blood vessels, although there is a lot of water in the body, but the blood circulation is insufficient, the blood is concentrated; nephrotic syndrome will also occur severe hyperlipidemia, the blood is more viscous.
Blood is highly coagulated, blood is concentrated, blood is viscous, and the blood flow in the lower extremities is slow...
Therefore, nephrotic syndrome is particularly prone to the formation of venous thrombosis of the lower extremities. Once the blood clot falls off, it is easy to cause pulmonary embolism.
Nephrotic syndrome has two serious fatal complications, one is infection and the other is hypercoagulable blood.
Fourth, he has membranous nephropathy, which is one of the most risk factors for venous thrombosis
Thromboembolic complications have been reported in 35% of nephrotic syndromes, with membranous nephropathy being the most susceptible type of thrombosis, the most common site of thrombosis being renal vein thrombosis, and of course, venous thrombosis of the lower extremities is also common [2].
Nephrotic syndrome is not a disease, but a common manifestation of many kidney diseases.
Diseases that cause nephrotic syndrome include diseases such as primary glomerulonephritis that originate in the kidneys, and renal damage caused by other diseases (secondary kidney disease) such as diabetic nephropathy, lupus nephritis, purpura nephritis, virus-associated nephritis, tumor-associated nephritis, etc.
Among them, a special type of membranous nephropathy in primary glomerulonephritis is more prone to thrombosis and embolism.
As for the reasons, it is not particularly clear at present, the mainstream view is related to environmental pollution, for example, Academician Hou Fanfan of Southern Medical University believes that it may be related to PM2.5.
Finally, the patient was diagnosed with membranous nephropathy.
Membranous nephrotic syndrome, causing severe hypoproteinemia is the most risk factor for venous thrombosis when plasma albumin
Therefore, when a nephrologist encounters nephrotic syndrome, he must tighten the string of anticoagulation, always be vigilant against the occurrence of blood clots and embolism, and make corresponding treatment.
5. Prevent pulmonary embolism and remember these 4 tips
Regarding the prevention of thrombosis, in general, when plasma albumin < 30g/L, it is necessary to routinely use aspirin or clopidogrel anticoagulation; when plasma albumin < 20g/L, it is necessary to routinely use the more effective anticoagulant drug heparin, etc., the purpose is to prevent the formation of thrombosis.
Of course, for most nephrotic syndromes, hormones suppress immune damage, repair the damaged glomerular filtration membrane, and reduce protein leakage, which is the most effective and fundamental treatment drug.
The disease of pulmonary embolism occurs suddenly, the condition is dangerous, and the progress is faster, making people invincible, or too late to rescue.
For example, a patient who has just completed major surgery feels well, recovers from bed activity, and suddenly dies of pulmonary embolism;
A pregnant woman, who was happy to have a child, died suddenly because of amniotic fluid embolism (also pulmonary embolism).
These endings sometimes make it difficult for patients and their families to accept, and even doctor-patient disputes occur.
Therefore, whether you have nephrotic syndrome or not, pulmonary embolism prevention is very important.
For example, people at high risk of pulmonary embolism are:
1. Long-term bedridden or sedentary: the blood flow of the lower limbs is slow, and it is easy to coagulation;
2. Phlebitis, varicose veins: it is also easy to occur and coagulation occurs;
3. Various reasons lead to blood in a state of hypercoagulability, such as long-term oral contraceptives, 8 hours, etc.;
4. Childbirth: Impurities in amniotic fluid are squeezed into the veins to form embolisms, and the sudden death of some women is amniotic fluid embolism of pulmonary arteries;
5. Severe trauma, long bone fracture: fat and other substances are absorbed into the vein after fracture, and long-term bed rest after fracture;
6. Malignant tumors: the shedding tumor body forms emboli;
For the above-mentioned high-risk groups, we must be vigilant and deal with them in advance.
Cause treatment to prevent recurrence.
Finally, here are 4 practical tips for identifying kidney disease and pulmonary embolism on a daily basis:
Health Tips——
1. The increase in foam in the urine may be proteinuria, and it is best to do urine routine testing if this situation is found;
2. Urine protein 3+ may be nephrotic syndrome, must do urine protein quantitative diagnosis;
3. Nephrotic syndrome is prone to thromboembolic diseases, sometimes very serious, should be treated in time;
4. For the inexplicable venous thrombosis of the lower limbs of young people, in addition to timely treatment, the cause must be traced.
bibliography
[1] LIGHT RW. Pleural effusions. [J]. The Medical Clinics of North America,2011,6(6):1055-1070.
[2] Zhang Wen, Diagnosis and Treatment of Thromboembolic Complications of Nephrotic Syndrome, Proceedings of the 3rd Annual Conference of Nephrologists in China, March 8, 2011.
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