glomerulonephritis

Glomerulonephritis - an infectious-allergic kidney disease. Etiology, pathogenesis. The development of diffuse glomerulonephritis associated with acute and chronic diseases mainly streptococcal nature. Streptococcal infection of the child during normal immunologic reactivity causes acute diffuse glomerulonephritis (acute, cyclical course of the disease). Partial defects in the immune systems of congenital or hereditary origin create conditions for the formation of chronic glomerulonephritis (protracted, fluctuating course of the disease), which is most often associated with circulating immune complexes, are fixed on the glomerular membranes In more rare cases, glomerular damage due to the formation of specific antibodies to the basement membrane. One of the factors of chronic inflammation in the kidney is the so-called tissue hypoplastic dysplasia, t. E. The backlog of renal tissue from the chronological age of the child.

The clinical picture. Acute diffuse glomerulonephritis first appears general weakness, headache, nausea, back pain, chilling, decreased appetite. There have facial pallor, pasty age, the amount of urine decreases sharply, but its relative density remains high. Oligoanuricheskaya phase lasts for 3-5 days, after which increases urine output, and the relative density of urine drops. Urine gets the color of meat slops. In cases microhematuria urine color can not be changed. At the beginning of the disease is dominated by fresh red blood cells, further distinguished mostly leached. Proteinuria (albuminuria) is usually moderate (3-6%), kept 2-3 weeks. At microscopy urinary sediment revealed hyaline and granular casts, in the case of gross hematuria-erythrocyte.

Edema is usually located on the face, there in the morning, in the evening decreasing. Prior to the development of visible swelling around 2-3 liters of fluid can be trapped in the muscles, the subcutaneous tissue. Hidden edema are detected with the help of the sample McClure.

The defeat of the cardiovascular system in the acute course of glomerulonephritis seen in 80-85% of children. Hypertension is less common than in adults, is held for long and by the end of 2-3 weeks of vanishes. Blood pressure rarely exceeds the age limit by more than 10-40 mm Hg. Art. There have been an extension of the heart borders, muted tones, systolic murmur or unclean first tone at the top, the second focus of the aorta (in the cases of hypertension), but more often the focus of the second tone in the pulmonary artery, changes in heart rhythm. Decrease in ECG P wave, ST bias interval, extension of electrical systole, T wave change Sometimes there is shortness of breath during stagnation in the pulmonary circulation. The liver is increased from 1-2 to 5-6 cm.

Research reveals endogenous creatinine clearance decrease in filtration capacity of the kidneys. Sample Zimnitsky shows decreased urine output, nocturia. High relative density of the urine indicates the stored concentration ability of the kidneys.

increased residual nitrogen in the blood (acute azotemia), urea. creatinine, cholesterol increased at equilibrium study acids and bases found in blood acidosis. Investigation of protein fractions reveals a decrease of albumin, increase of alpha- and beta-globulin. Long Dysproteinemia - a bad prognostic sign. The blood was leukocytosis and accelerated ESR.

After 2-3 weeks of swelling disappear, normal blood pressure, occurs poliurichesky crisis. Typically, the recovery occurs in 2-2.5 months. Extracapillary form of the disease characterized by acute onset of a pronounced and extrarenal urinary syndrome, the rapid development of renal failure with the outcome of uremia.

As a complication of the initial period may be a picture of renal eclampsia associated with cerebral edema and increased intracranial pressure.

Transition of acute glomerulonephritis in the current prolonged and undulating paired with a predominance in the clinical picture of various syndromes that allows you to select hematuric, edematous proteinuric, and mixed forms of the disease. Depending on the activity of the pathological process reveals an active phase and an inactive phase remitting phase.

Hematuric form is manifested severe hematuria, swelling of the face, hypertension. There have been signs of intoxication - general paleness, decreased appetite, lethargy. Frequent changes of the heart. In the active phase - fever, accelerated erythrocyte sedimentation rate, leukocytosis. There are various degrees of renal insufficiency. Proteinuria is never pronounced and does not exceed 1-3%.

Nephrotic (edematous albuminuricheskaya) form is characterized by widespread edema (both peripheral and cavitary), proteinuria, hypo and dysproteinemia, hyperlipidemia and hypercholesterolemia. Hypertension and hematuria expressed mild. For nephrotic form is characterized by a sluggish start and a long undulating course with periods of improvement and new exacerbations.

Mixed form occurs most heavily. Characterized resistant hypertensive syndrome, pronounced swelling, persistent proteinuria, hematuria, Dysproteinemia, uremia development. In the acute period when this form is possible with the development of oliguria acute renal failure. Diagnosis is based on data from urine tests, tests on Zimnitsky definition diuresis, urine culture, blood pressure measurement, blood biochemical analysis, sample McClure.

The differential diagnosis is carried out with interstitial nephritis, pyelonephritis, urolithiasis, hereditary nephritis, hemorrhagic diathesis.

Treatment. In the active phase requires strict bed rest for 4-6 weeks, shows the fruit and sugar or fruit and vegetable days: the child receives 10 grams of sugar and 50 grams of fruit per 1 kg of body weight; you need as quickly as possible (within 4-5 days) to expand the diet at the expense of vegetables and flour dishes. Introduction of protein restricted only in the first days of treatment, after which the child should be transferred to a full protein regime (2-2.5 g protein per 1 kg of body weight), including animal protein (cheese, milk, fish, meat later). It is advisable the introduction of vegetable oil diet. If there are signs of developing chronic renal failure shows the assignment of a strict diet Giordano-Giovannetti (potato-vegetable-fruit diet).

thirst mode, "Water blow" and other measures used in adults, is unacceptable for a children's hospital. Fluid restriction unnecessarily even when Edema syndrome. The amount of sodium chloride, including its content in food products must not exceed 1 g / day. The content of sodium in the diet increased gradually until the end of the physiological norm first month from the beginning of the disease (exacerbation) in the case of clinical and laboratory data indicate remission. All patients in the acute phase (or exacerbation) prescribe antibiotics. It is advisable to use drugs against streptococcal infections - penicillin, semisynthetic penicillins. Antibiotics are administered in a dosage of age with the change of the drug every 8-10 days. In nephrotic form due to increased clearance of antibiotics dosage is increased by 20-50%. Using corticosteroids prescribed drugs long-acting penicillin. Mandatory rehabilitation of chronic foci of infection (dental caries, chronic tonsillitis). Corticosteroids are effective in the treatment of many manifestations of glomerulonephritis, however, should not rush to their purpose in acute glomerulonephritis, and their effectiveness is questionable in a mixed form of the disease. Prednisolone administered at the rate of 1.5-2 mg / kg, or 40-50 mg per 1 sq. m body surface; the ineffectiveness of this treatment for 2-3 weeks, you can increase the dose or to appoint an additional immunosuppressive drugs action. The duration of the maximum dose of prednisolone 2-3 weeks, after which the dose is gradually reduced so that the total course of treatment lasts 2-3 months. By reducing the dose of the drug given mainly in the first half of the day. Supportive therapy is steroid intermittent courses (half maximal dose administered 3 days with 3 or 4-day intervals, or every second day, with intercurrent illness - daily).

Preparations 4 aminohinolinovogo series (rezohin chloroquine) can be assigned to a protracted course of the disease at a dose of 5.10 mg / kg 1-2 reception for 6-12 months. In forms of hormone glomerulonephritis shows the use of cytostatics - hlorbutin (leykeran) at a dose of 0.15 to 0.2 mg / kg for 6-8 weeks followed by dosage reduction of a factor of 2 and continuing treatment for 6-10 months, at a dose of cyclophosphamide 3-4.mg / (kg â,¬ day), azathioprine (3 to 4 mg / (kg day â,¬). becoming more widely used in non-clinical frologicheskoy find heparin in recent years, indirect anticoagulants, antiplatelet agents, indomethacin [2- 3 mg / (kg â,¬ d)] about in the same way as the treatment leukeran. to combat hypertensive syndrome using reserpine, hydrochlorothiazide, dopegit, clonidine.

Hypertension should not be regarded as a contraindication klecheniyu corticosteroids, but requires a longer limitation sodium, potassium injection drugs (potassium chloride 3-5 g / day, fruit - prunes, bananas), the use of antihypertensive drugs (reserpine, Dibazolum apressin, hydrochlorothiazide).

With the development of the child effects of acute heart failure is shown in / in a 0.1-0.2 mL of 0.05% strofantina solution of 20% glucose solution, can then be used digoxin. Magnesium sulfate is used as a sedative and vasodilator (0.2 ml of a 25% solution of 1 year of life).

Small swelling do not require special treatment, acute glomerulonephritis should refrain from the use of diuretics. It has a diuretic effect of the purine derivatives of (diuretin, theophylline), calcium (glkzhonat), potassium chloride.

When administered dihlotiazid significant edema (hydrochlorothiazide) - 25mg initially and then 50-75 mg for 5 to 6 days, furosemide - 20-40 mg per day, ethacrynic acid, triamterene. If no effect is assigned to the / m introduction by novurita 0.25 0.5 ml 1-2 times a week.

Apply aldosterone antagonists - spironolactone (aldactone). Assign up to 200 mg. aldactone inside for 10 days obychnoa-combination with hydrochlorothiazide or furosimidom.

In edematous albuminuricheskoy form shown in / plasma introduction gemodeza (5 ml / kg).

All children are widely prescribed vitamins A, B complex, C, R. One of the most effective methods of treatment of chronic renal failure is hemodialysis. In recent years significantly increased the effectiveness of kidney transplantation with the selection of antigens for HLA tissue compatibility of the donor. The expediency of the rehabilitation of sick children in a local nephrology resorts.

The prognosis of acute course of relatively favorable, with lingering and chronic current unfavorable.

Prevention of glomerulonephritis, and chronic renal failure is the treatment of chronic inflammatory lesions, urinary sediment study in every case of acute purulent-inflammatory diseases of the skin, nose and throat. Currently, developed methods for mass screening of children contingent on kidney disease, that allows to identify and treat the hidden, latent occurring nephropathy.