Pyelonephritis

Pyelonephritis is a nonspecific infectious kidney disease that affects the renal parenchyma, mainly interstitial tissue, pelvis and calyx. Pyelonephritis can be one- and two-sided, primary and secondary, acute (serous or purulent), chronic or recurrent.

Etiology, pathogenesis. Most often, pyelonephritis is caused by intestinal eserichia, enterococcus, proteus, staphylococci, streptococci. In HU patients with acute pyelonephritis and in 2/3 patients with chronic pyelonephritis, the microflora is mixed. During treatment, the microflora and its sensitivity to antibiotics change, which requires repeated urine culture to determine adequate uroantiseptics. It is necessary to remember the role of protoplasts and L-forms of bacteria in the occurrence of relapses of pyelonephritis. If the infection in the kidney is supported by protoplasts, the culture of urine does not detect them. The development of pyelonephritis largely depends on the general state of the macroorganism, reducing its immunobiological reactivity. Infection penetrates the kidney, pelvis and its calyx with hematogenous or lymphogenous pathways, from the lower urinary tract along the ureter wall, through its lumen - in the presence of retrograde refluxes. Important in the development of pyelonephritis have a stasis of urine, violations of venous and lymphatic outflow from the kidney. Pyelonephritis is often preceded by latent interstitial nephritis.

Acute pyelonephritis may be interstitial, serous or purulent. Apostematous nephritis and carbuncle of the kidney are possible subsequent stages of acute purulent pyelonephritis.

Symptoms, course. The disease begins acutely, there is a high (up to 40 degrees C) temperature, chills, tormentative sweat, pain in the lumbar region; On the side of the affected kidney - the tension of the anterior abdominal wall, sharp soreness in the costal-vertebral corner; General malaise, thirst, dysuria or pollakiuria. Acceding headache, nausea, vomiting indicate a rapidly increasing intoxication. Neutrophilic leukocytosis, aneosinophilia, pyuria with moderate proteinuria and hematuria are noted. Sometimes with worsening of the state of patients, leukocytosis is replaced by leukopenia, which is a poor prognostic sign. Symptom Pasternatsky, as a rule, is positive. With bilateral acute pyelonephritis, there are often signs of kidney failure. Acute pyelonephritis can be complicated by paranephritis, necrosis of the renal papillae.

Diagnosis. An important role in diagnosis is played by indications in a history of a recently transferred acute purulent process or the presence of chronic diseases (subacute septic endocarditis, gynecological diseases, etc.). Characteristic combination of fever with dysuria, pain in the lumbar region, oliguria, pyuria, proteinuria, hematuria, bacteriuria with high relative density of urine. It should be remembered that pathological elements in urine can be observed in any acute purulent disease and that pyuria can have extrarenal origin (prostate gland, lower urinary tract). On the survey radiograph, an increase in one of the kidneys in the volume is detected, with excretory urography - a sharp restriction of the mobility of the affected kidney during breathing, the absence or later appearance of the shadow of the urinary tract on the side of the lesion. Depressed cups and pelvis, amputation of one or more cups indicate the presence of carbuncle.

Treatment. In an acute period, appoint table number 7a, consumption of up to 2-2.5 liters of fluid per day. Then the diet is expanded, increasing the protein and fat content in it. With the development of metabolic acidosis, sodium bicarbonate is prescribed inside 3-5 g or iv in 40-60 ml of 3-5% solution. To improve local blood circulation, reduce pain, appoint thermal procedures (warming compresses, warmers, diathermy of the lumbar region). If the pain does not subside, then use antispasmodics (platyphylline, papaverine, belladonna extract, etc.).

Antibacterial therapy with nalidixic acid (nevigramone, blacks) is conducted, the course of treatment of which should last at least 7 days (0.5-1 g 4 times a day), nitrofuran derivatives (furadonin 0.15 g 3-4 times a day, Treatment course 5-8 days), nitroxoline (5-NOC), prescribed 0.1-0.2 g4 times a day for 2-3 weeks. The use of these drugs should be alternate. You can not simultaneously prescribe nalidixic acid and nitrofuran derivatives, as this reduces the antibacterial effect. During the first 5-6 days, especially with antibiotic-resistant infection, hexamethylenetetramine (urotropine) can be administered orally 0.5-1 g 3-4 times a day or iv in 5-10 ml 40% solution daily.

Combined treatment with antibiotics and sulfonamides is very effective. Selection of antibiotics is carried out depending on the sensitivity of microflora to them. Assign drugs of the penicillin group (benzylpenicillin for 1 000 000-2 000 000 units / day, oxacillin inside or in / m 2-3 g / day, ampicillin inside to 6-10 g / day, ampicillin sodium salt w / m or / In at least 2-3 g / day, etc.) or together with streptomycin (0.25-0.5 g / m 2 times per day). Also applied tetracyclines (tetracycline orally 0.2-0.3 g4-6 times a day, its derivatives-morphocycline, metacycline, etc.), antibiotics-macrolides (oletetrin, tetraolean inside 0.25 g 4-6 times a day ), Antibiotics-aminoglycosides (kanamycin IM in 0.5 g 2-3 times a day, gentamicin IM / 0.4 mg / kg 2-3 times a day), antibiotics-cephalosporins (cephaloridine, chain I / M or IV in the 1.5-2 g per day), etc. It should be remembered that it is necessary to change antibiotics every 5-7-10 days and to apply them in moderate doses with caution in case of functional kidney failure.

Of sulfanilamidnyh drugs prescribed urosulfan and etazol (1 g 6 times per day), sulfonamides long-acting (sulfapiridazin 1-2 g in the first day, then 1 g for 2 weeks, sulfamonometoksin, sulfadimetoksin). In most patients, changes in urine disappear after a few days, but antibiotic therapy should continue (usually a course of treatment lasts 4 weeks). In case of ineffectiveness of conservative therapy (more often with apostematous nephritis and kidney carbuncle) surgical intervention is indicated.

Chronic pyelonephritis can be a consequence of untreated acute pyelonephritis (more often) or primary chronic, ie, it can occur without acute effects from the onset of the disease. In most patients, chronic pyelonephritis occurs in childhood, especially in girls. In 1/3 of patients with normal examination, it is not possible to detect doubtful signs of pyelonephritis. Often, only periods of unexplained fever indicate an exacerbation of the disease. In recent years, cases of combined disease with chronic glomerulonephritis and pyelonephritis are becoming more frequent.

Symptoms, course. One-sided chronic pyelonephritis is characterized by blunt constant pain in the lumbar region on the side of the affected kidney. Dysuric phenomena in most patients are absent. During the exacerbation period, only 20% of patients have fever. In the sediment of urine, the predominance of leukocytes over other urine formations is determined. However, as the pyelonephritic kidney shrivels, the severity of the urinary syndrome decreases. Relative density of urine remains normal. For diagnostics, the detection of active leukocytes in urine is essential. In the latent course of pyelonephritis, it is advisable to perform pyrogenal or prednisolone test (30 mg of prednisolone dissolved in 10 ml of isotonic sodium chloride solution, injected intravenously for 5 minutes, 1, 2, 3 hours and a day later, the urine is collected for examination) . The prednisolone test is positive, if after introduction of prednisolone for 1 hour, urine releases more than 400,000 white blood cells, a significant part of which is active. Detection in the urine of Stringeemer cells - Malbina indicates only the presence of the inflammatory process in the urinary system, but does not yet prove the existence of pyelonephritis.

One of the symptoms of the disease in most patients is bacteriuria. If the number of bacteria in 1 ml of urine exceeds 100,000, then it is necessary to determine their sensitivity to antibiotics and chemotherapy drugs. Arterial hypertension is a common symptom of chronic pyelonephritis, especially bilateral.

The functional state of the kidneys is examined with the help of chromoscystoscopy, excretory urography, clearance methods (for example, determining the coefficient of cleansing of endogenous creatine and each kidney separately), radionuclide methods (renography with 1311 hippuran, kidney scan). In chronic pyelonephritis, the concentration capacity of the kidneys is disturbed early, whereas the nitrogen excretory function persists for many years. Developing as a result of disruption of tubular function, acidosis, as well as renal loss of calcium and phosphate sometimes lead to secondary parathyroidism with renal osteodystrophy.

With infusion urography, the decrease in the concentration capacity of the kidneys, the delayed release of the radiopaque substance, local spasms and deformations of the calyx and pelvis are first determined. In the following, the spastic phase is replaced by atony, the calyx and pelvis widen. Then the edges of the cups take a mushroom shape, the cups approach each other. Infusion urography is informative only in patients with urea levels in the blood below 1 g / l. In clinically unexplained cases, renal biopsies are used. However, in focal kidney lesions with pyelonephritis, negative biopsy data do not exclude the current process, since it is possible to hit uninfected tissue in the biopsy.

With the development of renal failure, pale and dry skin, nausea and vomiting, nosebleeds. Patients lose weight, anemia increases. Pathological elements disappear from the urine. Complications of pyelonephritis: nephrolithiasis, pionephrosis, necrosis of renal papillae.

Diagnosis often presents great difficulties. In differential diagnosis with chronic glomerulonephritis, the character of the urinary syndrome (prevalence of leukocyturia over hematuria, the presence of active leukocytes and Stringeemer cells - Malbin, significant bacteriuria in pyelonephritis), excretory urography, and radionuclide renography are important. Nephrotic syndrome indicates the presence of glomerulonephritis. With arterial hypertension, differential diagnostics should be performed between pyelonephritis, hypertensive disease and vasorenal hypertension. A characteristic anamnesis characteristic of pyelonephritis, urinary syndrome, the results of X-ray and radionuclide studies, detected by chromoscystoscopy, the asymmetry of dye excretion in the vast majority of cases allow one to recognize the disease.

The question of the presence of vasorenal hypertension is solved by intravenous urography, radionuclide renography and aortoarteriography.

Treatment of chronic pyelonephritis should be conducted for a long time (years). Begin the treatment should be with the appointment of nitrofurans (furadonin, furadantine, etc.), nalidixic acid (blacks, neviramone), 5-NOK, sulfonamides (urosulfan, atazol, etc.) alternating alternately. At the same time, it is advisable to treat cranberry extract. With ineffectiveness of these drugs, acute exacerbations of antibiotics are widely used. The antibiotic prescription should be preceded every time by the determination of the sensitivity of the microflora to it. Most patients have a monthly 10-day course of treatment. However, in some patients with such therapeutic tactics, virulent microflora continues to be sown from the urine. In such cases, continuous continuous antibiotic therapy is recommended with a change of drugs every 5-7 days.

With the development of renal failure, the effectiveness of antibiotic therapy is reduced (due to a decrease in the concentration of antibacterial drugs in the urine). With a residual nitrogen content of more than 0.7 g / L in the serum, therapeutically effective concentrations in the urine of antibacterial drugs can not be achieved. In the absence of kidney failure, spa treatment is indicated in Truskavets, Essentuki, Zheleznovodsk, Sairme, Bayram-Ali.