Hoʻomaopopo ka nephropathy Diabetic i kēlā me nā lehelee ma ka ʻaoʻao o ka mea i hoʻōla ai i ka hopena ma ke ʻano o ka hopena o ka metabolic o nā paka a me nā lipids ma ke kino. Hiki ke loli i ka hoʻololi ʻana i nā renom glomeruli, tubules, arterioles, a me nā lāʻau. Hoʻopilikia ka nephropathy diabetic i 70-75% o nā poʻe me kahi "maʻi maikaʻi".
Hōʻike mau ia iā ia iho i ke ʻano o kēia mau kūlana:
- ʻO ka sclerosis o nā ʻalopau o nā renal a me kāna mau lālā.
- ʻO ka sclerosis o nā arterioles.
- ʻO Glomerulosclerosis o ke kahe, ka nodular a me ka ʻano exudative.
- Pyelonephritis.
- Necrosis o ka palila renal.
- Nphrotic nephrosis.
- ʻO ka waihoʻana i nā tubula o nā māla o ka mucopolysaccharides, lipids a me ka glycogen.
ʻEnehana hoʻomohala
ʻO ka pathogenesis o ka nephropathy maʻi pānaʻi e pili ana me kekahi helu o ka metabolic a me hemodynamic kumu. Hoʻokomo pū ka pūʻulu mua i ka hyperglycemia (ke koko koko kiʻekiʻe) a me ka hyperlipidemia (kiʻekiʻe kiʻekiʻe o lipids a me / a lipoproteins i ke kahe koko. Hōʻike ʻia nā mea hemodynamic e ka hypertension arterial a hoʻonui i ke kaomi i loko o ka glomeruli renal.
Nui! Aia pū kekahi puʻupaʻa predisposition kahi hiki ke hoʻēmi ʻia.
ʻO nā loli hoʻololi
ʻO ka Hyperglycemia ka pilina nui ma ka kaulahao o ka hoʻomohala ʻana o nā ala o ka pūpū i ke kūpaʻa o ka "maʻi aloha". E kūʻē i ke kāʻei o kahi pae kiʻekiʻe o ka glucose, e hui pū ia i nā protein a me nā ʻākina o nā membula renal, e hoʻololi ana i ko lākou anatomical a me nā hiʻohiʻona physiological. Eia pū kekahi hapa nui o ka hopena o ka monosaccharides i ka palaki o ka huapalapala, e hoʻoulu ai i ka hana o nā protein kinase C a kōkua i ke hoʻonui i ka pono o nā pā vascular.
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya.jpg)
ʻO ka Hyperglycemia ke kumu nui etiological o ka hoʻomohala ʻana i nā pilikia o ka maʻi maʻi
ʻO ke hoʻonāukiuki i ka hopena o ka oxidation ka mea e hoʻokuʻu ai i nā nīnū manuahi e hiki ai ke loaʻa i ka hopena maikaʻi a hiki i ka hopena i nā mea huʻina o nā mea ola.
ʻO nā kiʻekiʻe kiʻekiʻe o nā lipids a me nā lipoproteins i ke koko ke kumu hou e hoʻomohala ai i ka nephropathy. Ke waiho nei ma ka papale o loko o nā arteri a me nā arterioles, ua hāʻawi ka glucose i kona ʻeha a hoʻonui i ka permeability. Hiki i nā lipoproteins haʻahaʻa-nona i hōʻemi ʻia i ka maʻi oxidation ke komo i loko o ka nui o ke kīpē o loko o nā kīʻaha koko. Hāpai ʻia lākou e nā ʻona kūikawā a puni ka mea huakaʻi kikoʻī e hoʻohui ai.
Nā mea hemodynamic
ʻO kahi kiʻekiʻe o ke kaomi o ka glomeruli o nā keiki ka mea e hoʻopili ai i ka neʻeʻana o ka pathology. ʻO ke kumu o ia ʻano hypertension ʻo ia ka hana o ka ʻōnaehana renin-angiotensin (ʻoi aku ka nui o ka hormone naiotiotin-II).
Ke hoʻonui nei i ke kahe o ke koko i loko o ke kanaka ka mea e kū ana i ka pane ʻana i nā mea āpau o luna, e lilo ana i mea hana i ʻoi aku i nā loli metabolic i ka hoʻomohala hou ʻana o ka pathal renal i kona ikaika pathological.
ʻIkepili hōʻike
ʻO ka nephropathy diabetic (code no ICD-10 - N08.3 a i ʻole E10-E14 p. 2) e kū pinepine i ke kiʻi o ka mellitus e pili ana i ka insulin. Aia nō me nā maʻi type 1 e pili ana i ka palaka ʻana i nā maʻi ma waena o nā kumu āpau o ka make ma nā maʻi. Me ke ʻano 2, lawe nephropathy i kahi lua (ʻo ka mea mua nā paʻakikī mai ka naʻau a me nā kīʻaha koko).
ʻO nā aʻalolo kahi kānana e hoʻomaʻemaʻe i ke koko o nā mea laʻa, nā huahana metabolic, nā mea inu. Hoʻopili wale kēia mau mea āpau ma ka ukiʻi. ʻO Glomeruli o nā palela, kahi e loli ai nā loli i ka maʻi diabetes, ua manaʻo ʻia he kānana. ʻO ka hopena ka mea haki i nā kaʻina kūlohelohe a me ke kaulike o nā electrolytes, ka hōʻoki ʻana o nā protein i ka urine, ka mea i ʻike ʻole ʻia e ka poʻe olakino.
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-2.jpg)
ʻO Glomeruli o kaʻeha - ka hana nui o ka kānana koko
Hoʻopilikia kēia e like me ka papa ʻōlelo penei:
- Nā wōwili mua - komo ka liʻiliʻi o nā ʻōmole liʻiliʻi.
- Ke holomua - hāʻule nā moleki nui.
- Ke piʻi nei ke koko, ke hoʻopiʻi hou i ka hana āpau.
- Hoʻopilikia hou ka hōʻino ʻana i ke kao i ka BP kiʻekiʻe.
- ʻO kahi hapa o ka protein i ke kino e alakaʻi i ka edema koʻikoʻi a me ka hoʻokumu ʻana o CKD, ka mea i hōʻike ʻia e ka hala ʻole.
No laila, ke kamaʻilio nei mākou e pili ana i kahi pōpoki ʻino, ʻo ka hopena o ka mea e pono ai ka hemodialysis, a ma nā hihia koʻikoʻi, kahi maʻi lela.
Kahi helu
Nui nā māhele i nā maʻi i nā keiki a me nā pākeke: ke ʻano kaukau ʻana o ka maʻi, ka hoʻonohonoho ʻana morphological a me ka helu ʻana ma nā pae.
Kauaka
I ka loaʻaʻana o ka protein i ka urine, ua hoʻoholo ʻia nā kiʻekiʻe o ka bun. Eia kekahi, e like me nā ʻōmole, ua helu ʻia ka nui o ka filtration glomerular, e like me nā kuhikuhi a ka mea i kū ai ke CKD a me kāna kūlana.
Puka no ka nānā ʻana i ka helu o ka kānana ma ka pākeke.
140 - makahiki (helu o nā makahiki) x ka nui o ke kino (i ka kg) x kaʻe. (ke kāne - 1.23, nā wahine - 1.05) / Mea hana (μmol / L) = GFR (ml / min)
Pula no ka nānā ʻana i ka GFR no nā keiki:
nā wahi hewa (ke ana o ka makahiki) x kiʻekiʻe (cm) / Mea hana (μmol / L) = GFR (ml / min)
Kūlana ʻo CKD | Ke poʻo inoa | Nā haki GFR (ml / min) |
Owau | ʻO ka heleʻana o nā patula e hoʻoholo ʻia e nā hana diagnostic ʻē aʻe, me nā maʻi o ka kānana a i ʻole kiʻekiʻe | 90 a maluna |
II | Nā helehelena o nā pūpū me nā helu liʻiliʻi o nā kānana glomerular | 60-89 |
III | Hōʻemi nā hoʻemi hōʻemi māmā ʻana | 30-59 |
IV | Hōʻemi ʻia i loko o ka helu filtration glomerular | 15-29 |
V | ʻO ka palaualelo ʻole | 14 a i lalo |
Laulima
ʻEhā mau papa nui, e like me ke ʻano o ka hoʻololi ʻana o ka anatomical a me ka physiological i ke kino o ka mea maʻi.
- Nā kuʻemikū o ka membrane o nā ʻāpana kōpal o kahi ʻano kūʻokoʻa.
- Hōʻailona i kahi o nā sela kikowaena glomerular o kahi liʻiliʻi (a) a i ʻole ke kaumaha (b).
- ʻO ka hana o nā nodules i loko o nā pūpū kikowaena (glomerulosclerosis).
- Sclerosis o kahi ʻano i haʻi ʻia.
Helu papahele
Hōʻike ʻia ke ʻano hana mua e ka hyperfunction o ka ʻōnaehana filtration. Hoʻoulu ia i ka hoʻomaka o ka maʻi diabetes. Hāpai ka poʻe ʻōhua e hoʻoneʻe i ka glucose mai ke kino i ka hiki, ke komo pū me nā hana hoʻokūkū. Ka hala ʻole ka protein (protein i loko o ka urine), me he mau hōʻailona lā o ka patology.
ʻO ka papa hana mua ka hōʻike hōʻike mua. Hoʻoulu ia i kekahi mau makahiki ma hope o ka loaʻa ʻana o ka "maʻi ʻala". Nā palalike o nā paia o nā arteri a me nā arterioles, akāʻaʻohe iki ka protein i ka urine, a me nā mea maʻi.
ʻO ke kolu ke kolu ke kahua o ka microalbuminuria. Ke hoʻoholo nei kahi pūʻulu noiʻi i ka heleʻana o ka protein i ka nui o 30 a 300 mg / lā. Hōʻike ʻia ka pōʻino o ka maʻi maʻi e ka neʻe o ka manawa i ke kahe o ke koko me ka ʻole o nā hōʻike ʻē aʻe.
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-3.jpg)
Urinalysis - ke kumu no ka hoʻopaʻaʻana i ka nephropathy maʻi maʻi
ʻO ka hā ʻehā - nā hōʻailona koʻikoʻi o ka nephropathy maʻi. Ke nui ka nui o ka protein i loko o ka waiʻai, nā hōʻailona o nā mea huna i ka hoʻokahe koko, a ʻike ʻia nā puʻu. Inā ma waena ka pae o ka proteinuria, ma ka maka o edema i ka maka a me nā wāwae. I ka hihia o ka nui o ka nui o ka protein mai ke kino, hōʻiliʻili ka pathological exudate i loko o ka ʻōpū, pleural, pericardial cavities.
ʻO ka papa hana ʻelima ka maʻi koʻikoʻi e hōʻike ʻia e ka sclerosis piha o nā moku ʻauʻau, ʻo GFR ma mua o 10 ml / min. Loaʻa ka kōkua i loko o ka hemodialysis a i ʻole ka hoʻololi ʻana i nā lālā, no ka mea, ʻaʻole nā hana hou o ka mālama ʻana.
Nā kiʻi haukapila
Hoʻopili nā pae o ka nephropathy maʻi i nā hōʻike a me nā hōʻike hōʻike. ʻO nā ʻano mua ʻekolu i manaʻo ʻia he preslinical, no ka mea, ʻaʻohe he mau hiʻohiʻona o ka palolo. Hiki ke hoʻoholo ʻia nā loli me ka hoʻohana ʻana i nā diagnostics laboratorium a i ʻole ma ka nānā ʻana i ka histological o nā maʻi renal.
Hōʻike nā hōʻailona hōʻeha i ka hā ʻehā, i ka wā e hoʻomaka ai nā maʻi e ʻōhumu e pili ana i kēia mau hōʻike aʻe:
- ka ʻōpū o ke alo a me nā haʻahaʻa haʻahaʻa;
- hoʻonui i ke koko;
- waiho kaumaha;
- nāwaliwali, nāwaliwali hana;
- hemo wale, he luaa
- nele o ka momona;
- makewai helehelena;
- cephalgia;
- ʻaʻano pōkole
- ʻeha ma hope o ka sternum.
Nā ʻōmai no ka haukapila
Hoʻolālā ʻia ka mālama maʻi maʻi maʻi e like me ka mea i hoʻolālā ʻia no nā poʻe maʻi me ka nephropathy a me ka maʻi nephrotic pale i ka maʻi filtration ma luna o 65 ml / min, me ka pathology renal i hui pū ʻia me nā maʻi maʻi ʻoi aku o nā hana 3 a me 4.
E koi ʻia ka hana hoʻokipa ma ka pilikia ma kēia ʻano.
- oliguria - kahi piula liʻiliʻi nui o nā urine i hoʻopuka ʻia;
- azotemia - kahi nui o nā mea kino i loko o ke koko;
- hyperhydration - kahi punawai o ka metabol-wai paʻakai, i hōʻike ʻia e ka hoʻokumu ʻana o ka edema;
- kuʻuna o ka metabolic acid - kahi hoʻonui o ke kahe o ke koko;
- hyperkalemia - kahi mahuahua o ka pāhana i loko o ke kahawai.
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-4.jpg)
ʻO ka hana o ka hoʻokele hoʻomanawanui a me ka hoʻoholo ʻana i ka pono o ka hoʻokipa ʻana, ʻo ia ka prerogative o ke kauka hele mai
Nā maʻi diagnostics
Ua wehewehe ʻo ka mea loea i ka maʻi o ka mea maʻi i ka maʻi maʻi, ke kiʻekiʻe o ke koko a me nā ʻokoʻa, ka hoʻomohala ʻana o ka ʻili. Hoʻomaopopo ka ʻike i ke ʻano o ka ʻili, ka paona o ke kino o ka mea maʻi, ka hele ʻana o ka edema a me ko lākou kaumaha, ka ratio ma waena o ka urine i loaʻa a me ka excreted i kēlā me kēia lā.
ʻO kahi hōʻike koko maʻamau (ʻo ka nui o nā kumuhana i hoʻokumu ʻia, ke kūlana coagulation, formula leukocyte, ESR), koiola (koi piha ka protein, albumin, C-reactive protein) i kahi. Ka loiloi nā ʻina i ka urine (ka nānā ʻana, ka microscopy sediment, ELISA o nā protein, nā moʻomeheu bacterial).
Ka hoʻoholo ʻia nā pae o GFR, mea hana, urea, cholesterol, glucose, a me nā mea heʻeke. Nā ʻano hana maʻi holo kino hou:
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-5.jpg)
- ʻO ka pōkole o nā pūpū a me ka ʻōpū;
- nā māla mololi ʻole;
- ECG, echocardiography;
- Dopplerograma o nā moku ʻaihala;
- X-ray o ka umauma, ʻōpū;
- nā hōʻailona o ka hormone thyroid a me ka parathyroid.
Inā pono, e hoʻouna ke kauka i ka mea maʻi no ka kūkākūkā me ka ophthalmologist (e kāpae i ka retinopathy diabetic), he cardiologist (ma ke ʻano he mau hōʻailona o ka puʻuwai naʻau a me ka arrhythmia), he endocrinologist (e kāohi i ka maʻi lalo), kahi angiosurgeon (e hana i kahi fistula AV e komo ana no hemodialysis).
Ka ʻokoʻa ʻana o ke ʻano maʻi
Pono neʻe i ka nephropathy diabetic mai ke nephrotic syndrome a me nā maʻi nephritic kūloko.
Hōʻike kūlohelohe | ʻO ka maʻi Neprotic | ʻO nā maʻi ākea nephritic | ʻO ka neā ʻana no ka maʻi diabetes |
I nā pae mua | Ke kūwili nei i nā wāwae a me ke alo | Ke koko a i ʻole ka protein i loko o ka urine, ka ʻaʻa, ke koko kiʻekiʻe | Hoʻolaha ka maʻi diabetes, hoʻonui iki i ka pomi |
Ke ʻano puhi a me ke ʻano | Heʻano nui paha | ʻUʻu ka lole liʻiliʻi | Me ka piʻi nui o ka nui o ka protein i ka urine, hoʻonui ka edema, hiki i nā ulia trophic wale nō |
HANʻI | Hoʻololi a hōʻemi paha | ʻO nā pinepine pinepine i loko o nā palena maʻamau | Nā ʻāpana keu |
Ke koko i ka kaomi | ʻAʻohe, ʻike ʻia i ka wā i hui pū ʻia me ka maʻi nephritic | Koi mau | Nalo ana |
Protein i loko o ka iomi | Aia ma luna o 3.5 g / lā | Lalo 3 g / lā | Mai ka waiwai ʻole i nā hōʻailona nui |
ʻO ka heleʻana o nā huahana nitrous ma ke koko | Hoʻonui ka hoʻokele o ka pathology | Ke nalowale nei a holomua paha | Mamuli o ka lōʻihi o ka maʻi |
ʻO nā hōʻike ʻē aʻe | ʻO ka hōʻiliʻili ʻana o ka exudate i loko o nā kahe i loko | Hōʻailona i nā ʻōhua hemorrhagic | E hōʻino i ka mea hoʻokalakupua ʻike, nā maʻi maʻi maʻi, waiho i ka hypertrophy ventricular |
ʻO nā hana hoʻokō hoʻomanawanui
Me ka hoʻomohala o nā pae CKD 1 a me 2, a me ka piʻi ʻana o ke kaomi koko, koi ʻia kahi meaʻai kūpono, ke kau ʻana i kahi nui o ka protein i ke kino. Hoʻopilikino ʻia kēlā kalona o kēlā me kēia lā e kahi endocrinologist a i ʻole mea iʻai. ʻO ka papaʻai ka mea i hoʻemi ʻia ma ka nui o ka paʻakai i hāʻawi ʻia i ke kino (ʻaʻole iʻoi aku ma mua o 5 g i kēlā me kēia lā).
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-6.jpg)
Ke kaupalena ana i ka nui o ka paʻakai i loko o ke kai - ʻo ka hiki ke hōʻemi i ka hoʻomohala ʻana o ka puffli
Hoʻoholo ʻia ka papa hana o ke ʻano kino no ka hapalua hola a hiki i 5 mau manawa i ka hebedoma. Ka hoole ʻana i ka hana ʻino (inu ʻole a inu i ka inu). I kēlā me kēia 3 mahina, pono e hoʻoholo i ka noho ʻana o ka protein i ka pāʻai, a no ke ana ʻana i ke koko i kēlā me kēia lā.
Hoʻopau ka endocrinologist i ke kumumanaʻo o ka insulin insulin a i ka hoʻohana ʻana paha i nā inikini hypoglycemic, inā pono, e hana ana i ka hoʻoponopono ʻana ma o ka hoʻopi ʻana ʻana a hoʻohui ʻana paha i kekahi lāʻau. He mea koʻikoʻi kēia no ka mea he hyperglycemia mea hoʻomohala i ka hoʻomohala ʻana o ka nephropathy maʻi.
ʻO ka lāʻau lapaʻau
ʻO kahi manawa i loko o ka mālama ʻana i ka nephropathy maʻi maʻi he nui ka emi ʻana o ke koko i nā helu maʻamau (ma ke ʻano o ka protein i loko o ka urine, pono ke koko i lalo o 130/80 mm Hg). ʻO nā huahana koho:
- ACE inhibitors (Perindopril) - ʻaʻole wale ia e hōʻemi i ke koko, akā e hōʻemi ana i ka nui o ka protein i hoʻopuka i loko o ka pāʻai.
- Hoʻopau i nā mea hōʻemi ʻehu o Angiotensin (Losartan, Eprosartan) - hōʻemi i ke koko, e hōʻemi i ka hana hoʻohui o nā keiki.
- Thaizide diuretics (Indapamide, Clopamide) - ka hopena i ka hoʻomaka mua ʻana, ʻoiai ʻo ka kānana kānana ma luna o 30 ml / min.
- Hoʻopuka i nā diuretics (waikawa ethacrine, furosemide) - i hōʻike ʻia i nā hana o nā hōʻike ākea o nephropathy.
- Nā beta-blockers (Atenolol, Metaprolol).
- Kālā lālani tubule kalapona (Verapamil).
I mea e hōʻemi ai i nā mea kuhikuhi o ka lipoproteins haʻahaʻa haʻahaʻa, koho ʻia nā statins (Simvastatin, Atorvastatin) a me nā fibrates (Ciprofibrate, Fenofibrate).
Hemodialysis
ʻAʻole i loaʻa i nā palapala lapaʻau hou nā loiloi e pili ana i ka manawa pono e hoʻomaka i ka hoʻomaʻemaʻe ʻana i ke koko ma o hemodialysis. ʻO ka hoʻoholo ʻana i ka pono, ʻo ia ka prerogative o ke loiloi i hele mai. I ka makahiki 2002, ua hoʻokuʻu ʻia nā alakaʻi Practical ʻEulopa, aia i kēia mau ʻikeʻakena:
- Pono e hoʻomaʻemaʻe ke hoʻomaʻemaʻe ma ke ʻano o ka hoʻokaʻina ʻana o ke kaila filtration glomerular ma lalo o 15 ml / min i hui pū ʻia i hoʻokahi a keu paha: ke kuʻi ʻana, ke kala ʻole ʻia a me ka hoʻoponopono ʻana, ke ʻano o ke kūlana kaiʻai, hōʻike ʻia e ka holomua.
- Pono nā hoʻomaʻemaʻe koko e hoʻomaka me GFR ma lalo o 6 ml / min, ʻoiai inā hoʻokō pono ʻia ke ʻano loea, a ʻaʻohe mau hōʻailona hou aʻe.
- Dialysis mua no nā poʻe maʻi e maʻi koʻikoʻi.
Kolo ʻia nā ʻōlelo KDOQI e hoʻomaka i ka dialysis ma lalo o nā kūlana:
- edema koʻikoʻi, ʻaʻole ʻāpono e hoʻoponopono i nā lāʻau lapaʻau;
- kānana kānana ma lalo o 15 ml / min;
- Urea - 30 mmol / l a malalo;
- kahi hōʻemi koʻikoʻi i ka momona a me ka pae o ka hana kino kino;
- ʻOi ka paʻakai koko ma mua o 6 mmol / l.
![](http://img.diabetesentity.com/img/diab-2020/8490/diabeticheskaya-nefropatiya-7.jpg)
Hemodialysis - kahi hana hoʻomaʻemaʻe koko hana hoʻohana ʻia i hoʻohana ʻole ʻia
Nā mea lawelawe
Hiki i kahi mea maʻi me ka nephropathy maʻi pāʻai e koi ai i nā ʻoi a hoʻolālā paha. No ka hana dialysis wikiwiki ʻole e loaʻa, kahi lōkole ka dialysis pōkole.
ʻO nā hana i hoʻolālā ʻia ka hoʻokumu ʻana o fistula arteriovenous, implantation o kahi prostical vascular, permanente a peritoneal catheter paha. ʻO ka hoʻokele a me ke pila paha nā angioplasty o nā moku kūleʻa hiki ke hoʻokō
Nā hana kūpono
ʻO ke kumu no ka pale ʻana o ka nephropathy a me nā pilikia ʻē aʻe he uku no ka maʻi maʻi. Inā ʻike ʻia kahi pathology, a ua ʻike ʻia ka albumin i loko o ka pāʻai, pono e lohi i ka hoʻomohala ʻana o ke ʻano penei:
- ka mālama pono ʻana i nā hōʻailona kuhikuhi o ke kō;
- ka nānā ʻana o ke koko i kēlā me kēia lā;
- kahi hoʻi i ka hāhi momona koko;
- lāʻau lapaʻau lāʻau;
- ka hana ʻana i kahi meaʻai hoʻohaʻahaʻa haʻahaʻa.
Me ka hoʻomohala ʻana o ka proteinuria koʻikoʻi, pono e mālama ʻia nā ʻōlelo aʻoaʻo penei:
- ka hoʻokō ʻana i nā hemoglobin glycated kiʻekiʻe (ma lalo o 8%);
- ke hoʻoponopono ʻana i nā kuhikuhi o ke koko (hiki i nā helu i ʻae ʻia - 140/90 mm Hg);
- ka hoʻokomo ʻana i ka nui o ka kō me ka meaʻai.
Eia naʻe, ua manaʻo ʻia ka hoʻololi ʻana o nā kumu mua o ka hoʻopiʻi ʻana. ʻAʻole hiki ke loaʻa ke koena. Hiki i ka poʻe loea ke hoʻolōʻihi i ka holomua o ka maʻi, mālama i ka nohona maikaʻi o ka mea maʻi. ʻO ka nānā ʻana a me ka pili pono i ka ʻōlelo aʻo e hele ana i nā kauka ke kī nui no kahi hopena maikaʻi loa no ka poʻe maʻi.