KIDNEYS

From Big Medical Encyclopedia

KIDNEYS [ren (PNA, JNA, BNA)] — the pair body of an uropoiesis playing an important role in providing a homeostasis of a human body and the highest animals.

The COMPARATIVE ANATOMY AND PHYSIOLOGY

Secretory bodies — P.'s analogs — are available for the majority one-celled and metazoans. At fresh-water protozoa and a row sea one-celled this function is performed by a sokratitelny vacuole, edges participates in osmoregulation, regulation of volume of liquids of a cell. Sponges and coelenterates are deprived of special secretory bodies.

On an embryonal origin secretory bodies of metazoans divide into 4 groups: nephridiums (proto - and metanephridiums); coelomoducts — the tubules which are formed as an outgrowth tseloma (see) and the allocations of reproductive products which are initially performing function; a nephromixium — a combination of elements of a nephridium and a coelomoduct; malpigiyeva the tubules developing from an outgrowth of intestines. Protonephridiums function at flat worms, nemertin, etc.; the animals possessing a coelomic cavity have metanephridiums (annelid) and coelomoducts (mollusks, cancroid, etc.); at arthropods an important role in excretion is played by malpigiyeva tubules.

The protonephridium begins a terminal cell with cilia, fluctuations to-rykh create negative pressure in a gleam of the nefridialny channel. At the same time liquid is sucked in, and from it substances, necessary for an organism, reabsorbirutsya, and unnecessary are excreted. The metanephridium opens in a coelomic cavity of nefridiostomy; liquid comes to system of tubules where from it a number of substances is soaked up, and the formed urine comes to a bladder and is removed through a nefri-disupport. Function of coelomoducts of invertebrates — a boyanusov of body of mollusks and antennalny gland of Crustacea — is very similar to function P. of vertebrata. The pericardiac cavity at mollusks is the rest of a tselom, in it through a wall of a ventricle of heart the liquid coming on the renipericardial channel to a renal bag is filtered, then it passes on primary and secondary ureter. In these departments of a coelomoduct glucose, natyuiya, chlorine is soaked up, potassium setsernirutsya, eventually hypotonic urine at fresh-water and isotonic urine at marine animals is formed. In antennalny gland the initial stage of an uropoiesis occurs in a coelomic sack, further isotonic liquid comes to a labyrinth, cells of an epithelium to-rogo are supplied with a brush border and participate in absorption of glucose, amino acids and nek-ry other substances. In canalicular system sodium salts can be soaked up; at fresh-water forms hypotonic urine is formed. Cells of antennalny gland are capable to secretion in urine of a paraa-minogippurat (PAGE), potassium and other substances.

In a phylogenetic branch vtorichnoroty the secretory body is absent at erinaceouses, tunicates, shchetinkoroty, but semi-chordates have, a pogonofor, golovokhordovy and vertebral. At oh-lanoglossa, the representative like semi-chordates, in the central circulatory lacuna special education — a ball through which substances from blood are filtered in a cavity of a trunk is had and from there are excreted by secretory tubules outside. The lancelet has no coelomoducts, and there are nephridiums with solenocytes which are not found more at one of vtorichnoroty.

At vertebrata in the course of evolutionary development consecutive change of three various secretory bodies is observed: pronephrous, or head kidney (pronephros); primary, average kidney (mesonephros), or volfovo body; final, or secondary, a kidney (metanephros) — see. Urinogenital system . Items of vertebrata are constructed by the uniform principle and represent the structures adapted for process of ultrafiltration which are connected to system of the tubules providing a reabsorption of biologically valuable components of a filtrate and secretion of a number of substances in urine. Only at nek-ry species of sea bony fishes the reduction of the glomerular device is observed; at them aglomerulyarny P. Odnako functions and in this case receipt in a gleam of nephron of isotonic protein-free liquid is noted; there is a reabsorption, in particular, of ions of sodium.

The research P. of Cyclostoma is of great interest. It is the most ancient group of vertebrates, and miksina are their only representatives deprived of osmoregulation and from-osmotichnymi the oceanic environment. In P. miksin there are large renal little bodies connected by short tubules to an are-hinefritichesky channel. Their existence at miksin, representing initially sea forms, demonstrates that the renal ball serves as a necessary element of the excretory body participating in ionic regulation.

In P. of a lamprey all main departments of nephron are differentiated, its tubules form the loop reminding a nephronic loop. However there is no P.'s division on cortical and marrow and therefore it is not formed and hyperosmotic urine is not emitted. The initial stage of an uropoiesis at a lamprey occurs in a glome which is located along all P. and has length to 9 cm. It consists of separate glomerul, in a cavity of each of to-rykh the cervical department of nephron supplied with a ciliary epithelium opens. The glomerular filtrate comes to proximal and distal departments of tubules — analogs of collective tubes — and further to an ureter.

In P.'s evolution at vertebrata changes of the processes which are the cornerstone of an uropoiesis are observed. At hematothermal animals, especially at mammals, arterial blood supply of P., speed of glomerular filtering sharply increases in P. of mammals is 10 — 100 times higher, than at the lowest vertebrata, at the rate on 100 g of the weight (weight) of a body at animal rather identical sizes. Increase in filtering was followed by equivalent increase in a canalicular reabsorption of the filtered substances that is caused by an intensification of work of cells on transport of electrolytes and nonelectrolytes, increase in permeability of intercellular substance in a proximal tubule. In P. of mammals, in comparison with the lowest vertebrata, activity of oxidizing enzymes, especially succinatedehydrogenases sharply increases, oxygen consumption increases, activity of Na-K-ATF-azy grows in proximal and distal tubules. Increase in a renal blood-groove, glomerular filtering and incessant reabsorption of huge amounts of the filtered substances, despite the increasing energy expenditure, were fixed in process of natural selection because this feature of P. provided big stabilization of composition of blood and created big independence of organisms of conditions of the environment. At animals with low level of glomerular filtering the device of secretion allowing to emit those substances which at hematothermal are only filtered and reabsorbirutsya forms. The item of sea fishes has ability to cosecrete bivalent ions, in this process the important role belongs to the ion-exchange processes connected with a simultaneous reabsorption of ions of sodium.

To P. of fresh-water fishes and mammals only the arterial blood inflows. The item of sea and fishes through passage, amphibians, reptiles and birds are supplied with blood from two sources: arterial — from an aorta to arterioles of renal balls and venous — on renoportalny system, on a cut flows blood from the tail of a body, she joins pericanalicular capillaries; all blood flows from P. on a renal vein. Biol, value of renoportalny system consists that it compensates rather low arterial blood supply of P. at all vertebrata, except mammals, and is a source for clarification of blood by means of secretion from products of exchange and surplus of bivalent ions at sea fishes.

Ability to increase a reabsorption of water in renal tubules at effect of antidiuretic hormone (ADG) appears in P. of amphibians and remains in P. at the subsequent classes of vertebrata. In P. of birds and mammals new function — the osmotic concoction of urine caused by emergence of marrow P forms. Relative increase in the size of marrow P. and length of the thin departments of loops of nephrons localized in it correlates with increase of its ability to osmotically concentrate urine.

The EMBRYOLOGY

In the pre-natal period is observed alternation of the same forms of the organization of secretory system what are found in phylogenesis. The pronephrous (pronefros) at an embryo of the person is formed of nephrotomes, or segment legs, on border of somites and splanchnopleuras. Originally continuous cellular tyazh soon get a tubular structure thanks to emergence in their thickness of segment tubules. The pronephrous is put ranging from 2 to 14 segments, i.e. in head and partly in truncal metameres of a body. Unlike tubules of a pronephrous of nek-ry Cyclostoma and fishes, and also larvae of amphibians, segment tubules of nephrotomes at an embryo of the person are not differentiated, and reductions are exposed.

Primary P. (mesonephros) in the form of pair education on both parties from a dorsal mesentery, as well as a pronephrous, develops from many nephrotomes of the corresponding truncal somites. Tubules of nephrotomes repeatedly branch. Each of side tubules terminates blindly in a mesenchyma of a nephrotome near the vascular ball formed by a branch of a ventral aorta. From the blind end of a tubule by the end of the 4th week of development the capsule covering a vascular ball forms. The opposite ends of tubules gather in the taking-away tubules which, merging with the taking-away tubules of the next segments, give rise to the general channel of primary P. called by a volfovy channel. This channel reaches a foul place on the right and at the left and opens in it.

In primary P.'s structure are noted lack of a strict segmentarnost in an arrangement of tubules of nephrogenic rudiments, communication of tubules with arterial vessels via the capsule of balls of renal (malpigiyevy) little bodies, formation of the general output channel for collecting urine and removal it outside through a foul place is found. However primary P. at a germ of the person does not function.

Secondary P.'s emergence (metanephros) at the end of the 4th week of development means a new stage in an organogeny of allocation. For 2 months of pre-natal development in a germ of the person exist primary and secondary P. Pervichnaya P. undergoes involution, but partly is exposed to a differentiation in connection with development of rudiments of gonads. Secondary P. at a germ of the person forms from a mesenchyma so-called metanephrogenic tyazhy caudal department of a trunk. Here nephrotomes of the next metameres merge in the cellular masses located in the form of tyazhy on both sides from a backbone. Future renal tubules in these tyazha are found in the form of cellular beams. Later in these beams cavities which become then the tubules which are repeatedly branching in all directions are formed. On the ends of tubules blind protrusions turn into buds which surround the vascular balls which arose in a mesenchyma tyazhy on the course of arterial branches. The opposite ends of tubules of beams approach tubular offsprings of a renal pelvis and open in them. The pelvis represents a venter of protrusion of a volfov of a channel. This protrusion becomes further an ureter.

At a fruit at the age of the VI month the system of renal tubules is difficult, the number of branchings reaches 6 orders, apprx. 120 nephrons connects to one collective canal opening in a small cup. From caudal situation P. moves up. Around collective channels metanephrogenic fabric turns into pyramids. Complexes of pyramids cause lobation embryonal the Item. The turn P. which is made around a vertical axis is followed by reorientation of concave edge of P. from a front position in medial.

ANATOMY

P. lie in retroperitoneal space (see) ekstraperitonealno, on both sides from lumbar department of a backbone, are also covered with a peritoneum only in front. On the right the peritoneum from the liver covering an upper pole of the Item passes to a front surface of P. This transition is called a hepatonephric sheaf. At the left the parietal peritoneum separates the left P. from adjacent loops of intestines.

Fig. 1. The diagrammatic representation of an arrangement of kidneys in relation to a backbone and XI, XII edges (a skeletopia, the back view): 1 — the lower pole of a left kidney, 2 — a diaphragm, 3 — the XI edge, 4 — an upper pole of a left kidney, 5 — a backbone, 6 — an upper pole of a right kidney, 7 — the lower pole of a right kidney.

Items are located at the level of XII chest and three upper lumbar vertebrae. P.'s gate are at the level of border areas of the I—II lumbar vertebrae. The right P. is located usually 2 — 3 cm below left, and its upper pole does not reach the XI edge. The XII edge is projected on the left P. approximately in the middle, and on right — on border of upper and average its thirds (fig. 1). At P. women are located below, than at men. Each P. occupies the hollow limited lateralno to a cross muscle of a stomach, behind a square muscle of a waist and medially — the big lumbar muscle covering a backbone. An upper third of P. appears out of this bed and rests against a diaphragm over a lateral arc-shaped sheaf.

Topografo-anatomichesky relationship with the next bodies at the right and left P. is various. A considerable part of a front surface of the right P. is closed by a liver, is closer to medial edge in front there passes the duodenum, and below — a bend of a colon (flexura colica dext.). The left P. a front surface above adjoins to a stomach, is slightly lower — with a pancreas and is even lower — with a small bowel. The spleen covers lateral edge of the left P. in front, and behind on it the descending colon goes down. A back surface of P. prilezhit to a diaphragm, a cross muscle of a stomach and a square muscle of a waist.

The item it is covered with the connective tissue capsule (capsula fibrosa), outside from a cut the adipose capsule (capsula adiposa) is located. The fascial covering P. consisting of front and back fascial leaves creates the pockets opened from top to bottom on the right and at the left. In P.'s fixing an essential role is played by a renal fascia. The bunches of connecting fabric departing from a fascia penetrate an adipose capsule and grow into the fibrous capsule P. and partly into an adventitia of a pelvis and large renal vessels. These bunches as if attract P. to a fascia. In the mechanism of fixing of P. also intra belly pressure and vascular bonds are of great importance.

Fig. 2. Macrodrug of a left kidney of the adult (back view): 1 — the lower pole, 2 — an upper pole, z — a renal artery, 4 — a renal vein, 5 — an ureter.

Form P. of the adult fabiform (fig. 2), color its bright brown. The weight (weight) of P. fluctuates from 120 to 200 g, length — 10 — 12 cm, width of 5 — 6 cm, thickness of 3 — 4 cm. Convex edge (margo lat.) it is turned lateralno and partly kzad. Concave edge (margo med.) it is directed inside, to a rachis, towards the same edge of opposite P. Razlichayut more convex front renal surface (facies ant.) and back (facies post.), and also poles — top and bottom (top and bottom the ends, T.). The upper pole is slightly more rounded off, covered with an adrenal gland, lower is as if pointed. The distance between upper poles of P. is less, than between the lower poles; longitudinal axes P. form the corner opened from top to bottom.

Fig. 1. Macrodrug of a right kidney (frontal section): 7 — - cortical substance of a kidney, 2 — renal columns, 3 — renal nipples, 4 — the basis of a pyramid, 5, 1 5 — krdvenosny vessels, 6, 14 — renal pyramids, 7 — renal gate, 8 — a renal bosom, 9 — a renal artery, 10 — a renal vein, 11 — an ureter, 12 — a renal pelvis, 13 — small renal cups, 16 — big renal cups, 17 — marrow of a kidney.

The concave medial edge of P. in a middle part has deepening — a renal bosom (sinus renalis), coming in the form of a bay into it паренхиму.^ the Entrance to this bosom limited to front and back lips is called renal gate (hilus renalis), in to-rykh the renal leg consisting of a renal artery, a renal vein is located and ureter (see). Between elements of a renal leg friable cellulose, limf, nodes and neuroplex lie. On a frontal section (tsvetn. fig. 1) fabric P. is accurately differentiated on a periblast — cortical substance of a kidney (cortex renalis) of yellow-red color and marrow (medulla renalis) having dense lilovokrasny color. In cortical substance P. alternation of more dark and less dark strips located radially is observed. Marrow P. is divided into 8 — 18 renal pyramids (Malpigi), between to-rymi 10 — 15 renal columns (columnae renales) — spurs of cortical substance are located. At each pyramid having the extent of 0,5 — 0,8 cm distinguish the basis turned to P.'s surface, and top (a renal nipple) directed towards a renal bosom. The border between brain and cortical substance is traced on the line connecting the bases of pyramids. The truncated and rounded off top of a pyramid forms a renal nipple (papilla renalis). It has 10 — 25 openings, to-rymi papillary channels come to an end, and they are continuation of collective renal tubules of renal pyramids. The location of these openings is called the trellised field. A pyramid together with a part of the cortical substance, adjacent to its basis, divided by brain beams into segments (lobuli corticales, T.), is considered as P.'s (lobus renalis) share. In cortical substance distinguish a radiant part (pars radiata) and the curtailed part (pars convoluta) alternating among themselves.

Tops of pyramids (renal nipples) are turned into cavities of small renal cups, number to-rykh from 8 to 10. Two or three small renal cups form big renal cups which open in the general urinal — a renal pelvis (pelvis renalis).

The item of the newborn is located more highly, than at a fruit, and remains lobular. Its surface is divided by deep furrows into primary shares corresponding to renal pyramids. Not quite issued renal little bodies at newborns are distributed on all thickness of cortical substance and lie densely. On the first year of life of distance between renal little bodies increase, the size of little bodies at the same time increases. The pulled lobular surface of P. usually remains at children up to 2 — 3 years.

Blood supply. The arterial system P. begins renal arteries which depart from a belly part of an aorta on one from each party: left — at the level of I lumbar vertebra, right, longer — at the level of II of a lumbar vertebra. Quite often there are additional renal arteries departing from an aorta or ileal arteries.

Fig. 2. Diagrammatic representation of a structure and blood supply of tissue of kidney (frontal section): 1 — a renal little body, 2 — the bringing vessels, 5 — a fascia of a kidney, 4 — an adipose capsule, 5 — the fibrous capsule, 6 — a radiant part, 7 — star-shaped venules, 8 — kapsulyarny branches, 9 — balls, 10 — interlobular arteries, 11 — interlobular veins, 12 — arc arteries, 13 — the basis of a pyramid, 14 — an interlobar artery, 15 — boundaries a share vein, 16 — renal pyramids, 17 — renal nipples, 18 — the trellised field, 19 — renal cups, 20 — papillary openings, 21 — papillary channels, 22 — marrow of a kidney, 23 — direct arterioles, 24 — direct venules, 25 — arc veins, 26 — border between cortical and marrow, 27 — a proximal part of a tubule of nephron, 28 — the capsule of a ball, 29 — a nephronic loop, 30 — the curtailed part, 31 — the taking-out vessels.
Fig. 3. Diagrammatic representation of segments of a right kidney (anterior aspect): 1 — the lower segment, 2 — the lower front segment, 3 — an upper front segment, 4 — an upper segment, 5 — a renal artery, 6 — an ureter.

In renal gate a renal artery, having supplied with thin branches a renal pelvis, cups and the fibrous capsule, shares on two main (front and back) branches, from to-rykh depart interlobar arteries. On the nature of branching and across territories of distribution interlobar arteries generally correspond to segmented arteries of the Item. 4 segmented arteries originate from a front branch: upper segment, upper front, lower front and lower segments (fig. 3). The back branch passes into an artery of a back segment. Share, arc and interlobular arteries depart from segmented arteries (tsvetn. fig. 2). Final branches of interlobular arteries perforate the fibrous capsule P. and anastomose with its vessels. Arc and interlobular arteries are sources of emergence of the bringing glomerular arterioles, or the bringing vessels (vas afferens) which form balls (glomeruli) of arterial capillaries (balls of the renal little bodies) participating in formation of a renal little body (corpusculum renale). The bringing glomerular arteriole to dia. 25 microns have well developed inner elastic membrane, outside from a cut smooth muscle cells lie. During the approach to a renal little body the last will be transformed to special juxtaglomerular cells, cytoplasm to-rykh contains the granules testimonial of their secretory function. The endothelium of glomerular circulatory capillaries has the cytoplasm perforated by a time and fenestra. Their continuation is the taking-out glomerular arteriole, or the taking-out vessel (vas efferens). On it blood goes to a capillary bed, in particular uric tubules where there is a network of tubular capillaries (a vokrugtrubochkovy capillary network). Juxtaglomerular arteries, i.e. arteries only with one network of capillaries, in cortical substance P. meet as an exception though they are ordinary where there are no balls or them it is not enough. So, in marrow direct arterioles form dense capillary networks between renal tubules and collective renal tubules of pyramids.

The venous system P. on a bigger extent repeats a structure of arterial system. From tubular capillaries of cortical substance blood gathers in star-shaped venules (venulae stellatae) which merge in radiarno the located interlobular veins. From capillaries of marrow direct venules form. From connection of interlobular veins and direct venules there are arc veins, and then interlobar, from to-rykh the renal vein falling into the lower vena cava forms. Often additional veins of P. V the left renal vein meet the left adrenal vein, the left ovarian vein (at women) or the left yaichkovy vein fall (at men).

Lymph drainage it is carried out through network deep limf, the capillaries and vessels which are located around arteries and veins of a parenchyma of P. and also network superficial limf, vessels. One of superficial networks is localized in the fibrous capsule P. In substance P. limf, capillaries cover renal little bodies and follow to a top of a pyramid on a circle of renal tubules and collective renal tubules. Taking away limf, the vessels subdivided on front and back leave P.'s gate to regional limf, nodes (mostly lumbar or celiac). On the way taking away limf, vessels as a part of a renal leg meet small limf. nodes. For limf, systems P. are characteristic numerous bonds with limf, vessels of an adrenal gland, liver, pancreas, and also small egg, an ovary, a worm-shaped shoot.

Innervation it is carried out by branches of a celiac texture, to the Crimea peripheral branchings of a vagus nerve and final branches of celiac nerves join. Set of nervous branches and ganglionic accumulations on the course of renal vessels is called a renal texture. It is better developed in front from a renal leg. As a part of a renal texture distinguish top and bottom aortopochechny nodes and numerous small renal nodes. Bonds of a renal texture with top and bottom mesenteric textures, with neuroplexes of the next bodies and with lumbar nodes of a sympathetic trunk are expressed.

Among the nerve fibrils making branches of a renal texture are found myelin and amyelinic, afferent and efferent. Sensitive nodes of a vagus nerve and spinal nodes are sources of an afferent innervation of P., in to-rykh sensitive neurons are located. Efferent nervous conductors of century of N of page (sympathetic and parasympathetic) go to smooth muscle cells of walls of veins P., cups and a pelvis; adrenergic nerve fibrils prevail.

In P.'s gate renal neuroplex is divided into the parava-screen textures accompanying vessels of the Item. Together with them nerves go deep into substance P. In brain and cortical substance nerve fibrils braid pyramids and P.'s segments and, accompanying the bringing glomerular arterioles, reach capsules of balls; a part of fibers goes to a periarterial pad. The wall of uric tubules is also supplied with nerve fibrils. In a wall of a renal artery sensitive nerve terminations are found, it is a lot of receptors in a wall of a renal vein. Receptor devices meet in a wall of a renal pelvis and in the fibrous capsule. The set of amyelinic nerve fibrils concentrates in the field of small renal cups where muscular sphincters are found.

Radioanatomy

Fig. 4. The survey roentgenogram of belly area is normal (a direct projection): shadows of kidneys are visible, the left kidney is located slightly above right.

On survey roentgenograms on intensity of a shadow of P. almost do not differ from surrounding fabrics, but in some cases it is possible to see an outside contour of P. (fig. 4). Rentgenol, the image of a parenchyma, P.'s vessels, renal cups, a pelvis and ureters is reached only at their artificial contrasting (see Piyelografiya, the Renal angiography, Urography). Situation P. is determined by distance from their poles to the centerline and a horizontal passing through the middle of a body of the II lumbar vertebra. The distance between the lower poles of P. across usually makes 11 cm, and between upper — 7 cm of P. are inclined by upper poles to the centerline, forming the corner opened down which makes 15 — 30 °, on average it is equal 20 — 24 °. In most cases the right kidney is located below left and is usually at the level of XII of chest — the III lumbar vertebrae, and left — at the level of XI chest — the II lumbar vertebrae. At 1/3 people both P. are located at the identical level, and at 5% the left P. — below right. At assessment of situation P. it is necessary to consider position of a body, and also depth of a breath at the time of the research. Upper poles of P. are better visible after the forced exhalation. Some diseases lead to disturbance of natural mobility or shift of the Item. Change of an inclination of a longitudinal axis P. can be a symptom of a disease of the body, next to it, confirm anomaly of development of P., and also various patol, processes in them (a tumor, a cyst, pyelonephritis, a nephroptosis, etc.). Degree of a smeshchayemost of P. in the vertical direction at breath and change of a body normal does not exceed height of a body 1,5 lumbar vertebras. The limit of a smeshchayemost of P. in the mediolateral direction is insignificant. There is a big variety of forms P. Distinguish two main options of a form of the x-ray image of P. — wide and narrow. Sometimes also triangular shape of P. Pravaya P. on roentgenograms is defined looks already, than left. Normal P.' contours usually equal, smooth and continuous, except for medial edge where they in the field of renal gate are not traced. In 10% of cases in an average third left, is more rare than the right P., triangular protrusion of an outside contour is noted — so-called humpbacked P. Inogda on P.'s surface retractions meet, as a result to-rykh its outline become uneven (a sign of the kept germinal lobation). Protrusion of upper or lower poles at P.'s gate or a spherical, club-shaped curve of an upper pole is occasionally observed. The true sizes P. do not correspond x-ray since it is normal of P. slightly of a rotirovana of rather vertical axis therefore their x-ray sizes are smaller, than true. Owing to skialogichesky features of a x-ray projection with increase in volume of a trunk of P. are located from a film further and, therefore, look big. According to X-ray anatomic researches of Moell (N. Moyop, 1956), the normal sizes P. average: men have right P. 12,9 X 6,2 cm, the left P. 13,2 X 6,3 cm; at women — right Item 12, Zkh of 5,7 cm, the left P. 12,6 X 5,9 cm.

There is a big variety of a form of pyelocaliceal system P.; the main forms — ampullar, branchy and mixed. On an otnoshe-sheniya to P. the pelvis can stand considerably from a renal bosom or directly be located knutr from its medial edge. Normal contours of pyelocaliceal system accurate, hollow rounded off, without uglovatost and protrusions, smoothly passing in nizhnemedialny department into an ureter. Big cups have acute, rastruboobrazny outlines. As small renal cups usually are located in two ranks according to front and back half of P., images of cups are imposed at each other. Therefore their detailed studying, especially for the solution of a question of initial changes, demands performance of slanting and aim pictures.

HISTOLOGY

On gistol, a cut of a renal parenchyma the cut renal tubules are visible, walls to-rykh consist of an epithelium. Along with tubules on a cut of cortical substance under review there are numerous renal little bodies (a little body of Malpigi). They represent the vascular ball surrounded with the capsule Shum-lyansky — Boumena.

the Diagrammatic representation of a structure of nephron and its communication with vessels of a kidney (according to E. F. Kotovsky): 1 — the capsule of a renal ball (Shumlyansky — Boumena), 2 — its internal part, 3 — a gleam of the capsule, 4 — its outside part, 5 — a proximal part of a tubule of nephron, 6 — a brush border, 7 — basal striation, 8 — the descending part of a loop, 9 — the ascending part of a loop, 10 — a distal part of a tubule of nephron, 11 — a collective renal tubule, 12 — a papillary channel, 13 — a transitional epithelium of small renal cups, 14 — an interlobar artery, 15 — an interlobar vein, 16 — an arc artery, 17 — an arc vein, 18 — a direct arteriole, 19 — a direct venule, 20 — an interlobular artery, 21 — an interlobular vein, 22 — the bringing vessel (the bringing glomerular arteriole), 23 — a glomerular capillary network, 24 — the taking-out vessel (the taking-out glomerular arteriole), 25 — a star-shaped vein, 26 — the peritubulyarny capillary network (a cortical part), 27 — endoteyaiotsit the bringing vessel, 28 — a juxtaglomerular cell, 29 — a dense spot of a distal part of a tubule. Within the diagrammatic representation of a histologic structure of the respective sites of nephron is given (cross section).

The initial base unit of P. — nephron — includes a renal little body and a canalicular link (tsvetn. fig. scheme). Contents of a renal little body is vascular (malpigiyev) a ball. In it there are about 50 circulatory capillary loops which do not have cross soustiya. The last loop proceeds in the taking-out vessel. The glomerular circulatory capillary has the thin wall constructed of an endothelium (fenestrated endotheliocytes) in which a numerous time to dia is well distinguishable. 40 — 100 nanometers. Under an endothelium the basal membrane is located, edges consists of 3 layers: two rather leaky — lamina an eider of int. and ext. from the endothelial and epithelial parties with a respectively thickness of 80 — 100 nanometers and the tight fibrous inner layer — lamina densa 120 nanometers thick. The general thickness of a basal membrane makes 240 — 360 nanometers. The basal membrane separates an endothelium from special cells — podocytes which form big and small shoots. The last directly cover a basal membrane from the outer side. Between shoots there is a podpodotsitarny space. The surface of a basal membrane, free from shoots, has a so-called slit-like diaphragm with a time to dia. 5 — 12 nanometers. Podocytes are covered with the glycocalyx including acid glikozaminoglikana with numerous anion groups. The basal membrane of glomerular capillaries not continuous, it is interrupted in places where kernels of endotheliocytes are located. In these sites there are mezangialny cells (mesangiocytes) reminding pericytes of usual capillaries.

An outside part of the capsule of a ball is continuous, constructed of a flat epithelium which turns into a cubic epithelium in the place of the beginning of an uric, or gyrose, renal tubule.

Fig. 5. Microdrug of a renal little body according to J. A. Rhodin: 1 — an afferent arteriole, 2 — an efferent arteriole, 3 — a gleam of glomerular capillaries, 4 — a glomerular filtrational membrane, 5 — a gleam of the capsule of a ball, 6 — kernels of cells of an outside part of the capsule of a ball, 7 — kernels of cells of the interior of the capsule of a ball, 8 — kernels of endothelial cells, 9 — kernels of mezangialny cells, 10 — a vascular pole of a renal ball, 11 — kernels of juxtaglomerular cells, 12 — peritubulyarny capillaries; X 1200.

The renal little body (fig. 5) has diameter apprx. 200 microns. It represents the roundish education consisting of a ball of capillaries (wonderful network of capillaries — rete mirabile) and the capsule surrounding it. Distinguish a vascular pole of a little body (the bringing glomerular arteriole, or the bringing vessel enters a little body here, and there is a taking-out glomerular arteriole, or the taking-out vessel), and on the opposite side — a canalicular pole (from where the tubule begins uric, or renal). In a zone of a vascular pole between bringing and taking out vessels 4 types of cells forming a periarterial pad meet. Its basis is made by the epithelial cells lying directly on a basal membrane of the bringing glomerular arteriole. They replace smooth myocytes of a wall of an arteriole here. Their cytoplasm contains acidophilic granules. In triangular space between accumulation of these cells and a wall of the taking-out vessel there is an ovoidny formation a number of the lying prismatic cells, a so-called dense spot (macula densa) relying on group of special juxtaglomerular cells (cells Gore-magtiga) which fill a top of a triangle between vessels and a dense spot. The fourth group of cells is localized in a crack between a renal little body and the taking-out glomerular arteriole (vas afferens). These are mezangialny cells, mesangiocytes, or Bekher's cells, a role to-rykh it is not found out yet. The periarterial pad is considered responsible for production of hormone of a renin.

In a canalicular link of nephron distinguish proximal department, a loop with the descending and ascending parts and distal department. The wall of a renal tubule consists of a single-layer epithelium. In proximal department about 14 mm long and a wall 50 microns thick make cubic and low prismatic nephrocytes. These are large heteropolar cells, distinctiveness to-rykh is existence on a free pole of a brush border. At other cells on a free pole there are a lot of vesicles. The opposite pole of a cell is fixed to a basal membrane. Here in cytoplasm of a basal part of a cell there are a lot of mitochondrions, vacuoles and a pigment meet.

In an uric or renal tubule direct and gyrose sites of uneven thickness alternate. In proximal department crimpiness of a tubule is sharply expressed (gyrose a renal tubule, T., or tubule of the I order). Gyrose is also a distal department of nephron. The descending and ascending parts of a nephronic loop belong to direct tubules. Throughout the last thickness of a tubule changes. So, its average site is represented to thinner, its wall is constructed of flat cells, kernels to-rykh act in a gleam of a tubule. A wall of distal department, in Krom connect the ascending part of a loop (a direct tubule) and gyrose a tubule (the II order), it is constructed of the cubic cells which do not have a brush border. Gyrose the tubule of distal department contacts to a renal little body and from here goes to a collective renal tubule. Nephron reaches a limit with this binding part. The Nabolshy extent nephron is located in cortical substance. In marrow, in outside and internal its zones, and also in brain beams (renal columns) there are direct tubules, i.e. both knees of a nephronic loop. Collective tubules pass in pyramids, coming to an end as papillary channels on a top of a pyramid (a renal nipple). From total quantity of nephrons (2 — 2,5 million in both kidneys) 4/5 are located in cortical substance and only V5 a part is localized on border with marrow. These are so-called yukstamedullyarny nephrons; they surpass cortical nephrons in the size of balls and length of thin department of a nephronic loop.

Length of an uric tubule of each nephron reaches 50 mm. Total length of all tubules in two kidneys approaches 100 km, the surface of the epithelium covering them makes 5 — 6 m 2 .

The small renal cups accepting urine from papillary channels have thicker wall. The epithelium covering them prismatic, cells lie in two ranks. The thin basal membrane separates an epithelium from a muscular coat of a wall of a cup: smooth muscle cells have longitudinal and spiral orientation. Outside each cup is surrounded with friable connecting fabric (an extima, T.). Smaller wall thickness of a cup on a circle of a nipple of a pyramid attracts attention.

With transition of cups to a pelvis the epithelium becomes multirow, at the same time in the basis there are smaller cells, and is closer to a surface light cells with large kernels lie. The muscular coat of a wall of a pelvis is considerably thickened. In it division into longitudinal and spiral layers clearly is designated. The extima of a pelvis turns into accumulations of the friable cellulose filling intervals between vessels in a renal bosom.

PHYSIOLOGY

P. are one of the main homeostatic bodies, they participate in regulation of concentration of osmotically active agents, ionic structure, acid-base equilibrium and volume of liquids of internal environment of an organism, perform excretory, metabolic, endocrine functions. In kidneys process of education is carried out urine (see). P.'s activity is regulated by efferent nerves and nek-ry hormones. Diverse functions P. processes of ultrafiltration of liquid in renal balls (balls of renal little bodies) are the cornerstone, of a reabsorption and secretions of various substances cells of renal tubules, synthesis in P.'s parenchyma of new connections. Disturbance of various functions P. can be followed by emergence of hypostases, hypertensia, uraemias, acidosis, etc.

Process of an uropoiesis

In the 40th 19 century along with V. Boumen's hypothesis, according to a cut of a cell of renal tubules cosecrete the substances which are subject to removal, and glomerular circulatory capillaries of a renal (malpigiyev) little body emit salts and the water which is washing away these substances, K. Ludvig stated a hypothesis filtrational reabsorbtsionnogo the mechanism of an uropoiesis. He believed that in renal balls there is filtering of liquid, a number of substances is soaked up in renal tubules, and unnecessary components are excreted with urine. In the 70th 19 century. R. Gey-dengayn proved the provision on a role of canalicular secretion in the mechanism of an uropoiesis. In the 20th 20 century when there was available a micropuncture of nephron, value of glomerular filtering, a canalicular reabsorption and secretion for process of an uropoiesis was experimentally shown. In the 50th 20 century Virts, and Kuna (H. Wirz, V. of Hargitay, W. Kuhn) installed by Hargitya a role of a rotary counter-current flow system in the mechanism of osmotic concoction of urine.

The initial stage of an uropoiesis is connected with ultrafiltration in balls of renal little bodies from a blood plasma of almost protein-free liquid containing all substances dissolved in plasma. Normal through both P. there pass 20 — 25% of the blood which is thrown out by heart in 1 min. (apprx. 1200 ml in 1 min.). Through cortical substance P., weight to-rogo makes 70 — 75% of all kidney, 92,5% of amount of the blood proceeding through P. proceed i.e. through 1 g of cortical substance 4 — 5 ml of blood in 1 min. proceed. Feature of a renal blood-groove consists that at fluctuations of the ABP from 90 to 190 mm of mercury. its level remains to constants, also the volume of glomerular filtering is highly stable. Total quantity of the ultrafiltrate which is formed in both P. makes apprx. 120 ml, 1,73 sq.m in 1 min. The filtrational fraction — a share of the filtered liquid from the blood plasma proceeding on glomerular circulatory capillaries, makes 19%.

Motive power of glomerular filtering is the difference between the hydrostatic pressure created by cardiac performance, and oncotic pressure of proteins of a blood plasma. At a micropuncture research it was established that at the ABP apprx. 120 mm of mercury. in glomerular circulatory capillaries pressure makes 45 — 52 mm of mercury. Oncotic pressure of proteins of plasma belongs to forces counteracting ultrafiltration (16 — 26 mm of mercury.) and pressure of liquid in the capsule of a ball (8 — 15.mm hg).

Swing pressure creates the effective filtrational pressure promoting process of ultrafiltration of liquid, a cut makes apprx. 10 mm of mercury. During ultrafiltration of liquid concentration of proteins grows in a blood plasma of glomerular circulatory capillaries, oncotic pressure increases and effective filtrational pressure decreases.

In the course of glomerular filtering liquid passes through three layers — an endothelium of capillaries, a basal membrane and cells of an epithelium of a visceral layer of the capsule (podocytes). Cells of an endothelium have the big time in nek-ry cases closed by diaphragms (fenestrated endotheliocytes, T.). At a normal blood-groove the largest proteinaceous molecules form a barrier layer on a surface of a time of an endothelium and complicate passing of albumine through them. Passing of proteins through a basal membrane of a renal ball is interfered by negatively charged molecules — polyanions in a matrix of a basal membrane and a sialoglikoproteida on a surface of podocytes. Change of size of a charge of a time influences permeability of the glomerular filter. Reduction of release of substances in comparison with inulin begins at increase in radius of a molecule more than 1,80 — 2,20 nanometers. So, the clearance of a myoglobin (1,88 nanometers) in relation to clearance of inulin makes only 75%, ovalbumin (2,73 nanometers) — 22%, hemoglobin (3,18 nanometers) — 3% — it is less than 0,01% of seralbumin (3,55 nanometers).

Via the glomerular filter liquid with insignificant protein content comes to a gleam of the capsule of a ball, in a cut the same amount of neioniziro-bathing crystalloids (glucose, urea, creatinine) and almost same amount of electrolytes, as contains in a blood plasma. Small distinctions of ion concentration in both liquids are defined by linkng of a part of electrolytes with protein, influence of a Donnan equilibrium (see. Membrane equilibrium ) and the fact that a part of volume of plasma is occupied with protein. Linkng of electrolytes with protein more affects ultrafiltration of bivalent cations. Concentration of calcium is equal in a blood plasma to 2,5 mmol/l, but 46% of calcium are connected with protein; in renal balls 47,5% in the form of ions and 6,5% of the connected calcium in the form of complexes of calcium with citrate, phosphate and other anions are filtered. Concentration of magnesium in plasma makes 0,7 — 1,15 mmol/l, 32% of magnesium are connected with protein; in renal balls 55% of ions of magnesium and 13% in the form of complexes (table) are filtered.

Table. CONCENTRATION IN the BLOOD PLASMA of the MAIN INORGANIC AND ORGANIC MATTERS, THEIR FILTERING, the REABSORPTION AND EXCRETION KIDNEYS is NORMAL



Reabsorptions and secretion of substances in proximal department of nephron. The most part of the filtered substances reabsorbirutsya in proximal department of nephron, all physiologically valuable nonelectrolytes and apprx. 2/3 ions of sodium, the chlorine and water which came to a gleam of nephron are completely soaked up. Feature of a reabsorption in proximal department of nephron is that all substances are soaked up with osmotically equivalent water volume, and liquid in a tubule remains to almost izoosmotichny blood plasma. It is caused by high. permeability of a wall of a tubule for water.

Fig. 6. The diagrammatic representation of nephron with the indication of localization of a reabsorption and secretion of electrolytes and nonelectrolytes in renal tubules: in a renal ball (1) there is an ultrafiltration of various low-molecular substances, water and trace amounts of protein; substances reabsorbirutsya from canalicular liquid in blood or cosecrete in a gleam of a tubule (the direction of transport is specified by an arrow). Figures designated various departments of tubules: gyrose (2) and a straight line (3) parts of proximal department of nephron, thin descending (4), the thin ascending (5) and thick ascending (6) part of a Henle's loop, distal gyrose department of nephron (7), binding department (8), a collective tube of cortical substance (9) and marrow (10), belliniyev a channel (11).

Cells of a proximal gyrose renal tubule actively reabsorbirut ions of sodium, the ground mass of bicarbonate, but a wall of this part of nephron badly of a pronitsayem for Cl is soaked up here - . Potential difference through a wall of a tubule — apprx. 2 mV. After the soaked-up substances water leaves, the volume of contents of a tubule decreases, and concentration of Cl increases in it - , edges in a final segment of a gyrose tubule raises by 1,4 times in comparison with an ultrafiltrate. In the last (direct) part of proximal department of nephron a wall highly of a pronitsayem for Cl-, and it on intercellular intervals moves to pericanalicular liquid owing to a difference of concentration; partially in this department there is also an active reabsorption of sodium through a cell. In proximal department of nephron also potassium, calcium and other electrolytes and nonelectrolytes (fig. 6) is soaked up.

Mechanism of a reabsorption of sodium through a cell consists in the following. Through an apical membrane sodium is included into a cell on an electrochemical gradient since in intracellular liquid concentration of sodium is lower and there is a negative charge in relation to liquid of contents of a tubule. The movement of sodium to basolateral membranes comes from an apical membrane not diffuzno through all cytoplasm, and, apparently, on the isolated ways — on intracellular system of the tubulotsisternalny cytoplasmic reticulum connecting apical and basolateral surfaces of a cell. In membranes of the last there is an enzyme which performs function of a sodium pompe — Na-, K-ATP-ase. In cells of tubules of a kidney of Na-, K-ATP-ase regulates constancy of ionic structure of a cell, deleting from it sodium and carrying out transfer in cytoplasm of potassium. This enzyme provides also transcellular transport of sodium. It is not always connected with secretion by a cell of potassium, in many cases large amounts of sodium together with chlorine or other anions are soaked up.

Earlier believed that the reabsorption in proximal department of nephron is obligate, obligatory, non-regulated. It turned out that it is influenced by catecholamines, hormones. E.g., parathormone reduces a reabsorption of liquid from proximal department of nephron. For a reabsorption of substances and water in this tubule high-permeability of cellular contacts has importance very much. In P. of mammals the electric resistance of a wall of a proximal tubule makes 5 ohms/cm2, it is equal in a distal gyrose tubule 350 ohms! cm2, in initial departments of collective renal tubules — 1000 ohms! cm2. Glucose, amino acids, apparently, are not soaked up on intercellular ways, on the contrary, the reabsorption of a number of electrolytes and water in many respects is defined by permeability of these educations. Regulation of a reabsorption of liquid on intercellular intervals depends on hydrostatic pressure in pericanalicular vessels, oncotic pressure in capillaries, etc.

Reabsorptions of glucose. More than 100 mg of glucose in 1 min. come to a gleam of nephron with an ultrafiltrate, it reabsorbirutsya almost completely by cells of proximal department of nephron, and with urine in days no more than 130 mg are excreted. The return absorption of glucose depends on quantity of special carriers in membranes of cells of proximal department of nephron and speed, about a cut they transport glucose in a cell. Excretion of glucose begins only when the hyperglycemia and intake of glucose in an ultrafiltrate are so considerable that the amount of the filtered glucose exceeds reabsorbtsionny ability of tubules i.e. when all carriers are occupied. The reabsorption of glucose from a gleam of a tubule in blood happens to the help of the process which received the name «it is secondary active transport». In a membrane of a brush border there are special carriers for glucose, the movement to-rykh through a membrane depends on presence of sodium. On outer side of a plasma membrane of a cell from a gleam of a tubule carriers form a complex with glucose and sodium, and then conditions for moving of these substances to cytoplasm are created. Need of a carrier for transport of glucose through a plasma membrane is caused by the fact that glucose is insoluble in lipids and cannot easily pass through a plasma membrane in a cell. The movement of this carrier is oppressed by inhibitor of transport of sugars floridziny. The inner surface of a cell is negatively charged, in it concentration of sodium is lower, than in a gleam of a tubule, and intake of sodium through a membrane of a brush border in cytoplasm on a gradient of electrochemical potential creates conditions for transport of glucose through the same membrane against a concentration gradient in a cell. Penetration of glucose into a cell through a membrane of a brush border is the slowest stage at a reabsorption of glucose. Further glucose moves on cytoplasm, reaches basolateral plasma membranes, transfer of glucose through which in intercellular liquid happens also to participation of a carrier sensitive to a flo-ridzin, but presence of sodium is not required any more. Thus, active transport of sodium from a cell for which energy of cellular metabolism is spent promotes decrease in its intracellular concentration, and conditions for receipt through a membrane of a brush border of glucose on the mechanism of secondary and active transport are created. After introduction to blood of glucose the maximum ability of tubules to reabsorbirovat glucose can be measured. This indicator is normal relatively a constant, it changes at nek-ry fiziol. and patol, states. The maximum reabsorption of glucose decreases at hron, P.'s diseases, an end-stage of an idiopathic hypertensia, an addisonovy disease; raises at an acromegalia, a lipoid nephrosis, etc. Emergence of glucose in urine (see. Glycosuria ) it can be caused by disturbance of its reabsorption in renal tubules or depend on disturbances of carbohydrate metabolism, napr, owing to a hyperglycemia at a diabetes mellitus. At the same time loss of glucose with urine can reach 100 g a day.

Reabsorption of amino acids. In a glomerular filtrate the same concentration of amino acids, as well as in a blood plasma — 2,5 — 3,5 mmol/l. In usual conditions about 99% of the filtered amino acids are exposed to the return absorption, and this process happens hl. obr. in initial parts of a gyrose renal tubule of proximal department of nephron. Amino acid connects in a membrane of a brush border to the site, specific to it, on a carrier, it attaches sodium, and the complex moves in a membrane, releasing amino acid and sodium in cytoplasm. The quantity of carriers limited therefore after their connection with the corresponding amino acids surplus of the last remains in canalicular liquid and is excreted with urine.

The assumption of existence of one type of carriers for different amino acids is based that at introduction of excess of one amino acid excretion of all amino acids only of this group amplifies. Carriers for the main amino acids — diamino acids (cystine, a lysine, arginine, ornithine), acid amino acids — dicarbonic (glutaminic to - you, asparaginic to - you), imino-acids and glycine (proline, oxyproline, glycine), neutral amino acids (valine, a leucine, an isoleucine, etc.), beta amino acids are described (beta alanine, beta and aminoisobutyric to - you). The amino acids which came to a cell move to lateral and basal to plasma membranes through which removal is carried out by the facilitated diffusion. In a brush border on its surface turned into a gleam of a tubule, there are peptidases which are carrying out hydrolysis of peptides, and the formed amino acids are soaked up by the same cells. It is suggested that peptidases of a brush border participate as well in a reabsorption of amino acids. Increase in excretion of amino acids P. (see. Aminoatsiduriya ) it can be caused by the hereditary or acquired by disturbance of one or several systems of transport of amino acids either absence or low activity in an organism of enzymes of a catabolism of a number of amino acids.

Reabsorptions and secretion of protein. During the filtering liquid contains a small amount of proteins in renal balls, among them there are changed proteins, and also polypeptides and splinters of proteinaceous molecules, the size to-rykh less than diameter of a time of a basal membrane. The most part of the polypeptides and proteins which came to a cavity of the capsule of a ball is hydrolyzed, and amino acids reabsorbiru-tsya in blood. Daily excretion of protein with urine normal does not exceed 100 — 150 mg; at nek-ry patol. states the proteinuria reaches 50 g a day. Protein in urine can appear because of damage of a basal membrane of a renal ball when it is filtered more, than can reabsorbirovat tubules; as a result — disturbances of a reabsorption of protein at a normality of glomerular filtering and at secretion by glands of uric ways. The reabsorption of proteins happens in proximal department of nephron with the help pinocytic (see). The substances adsorbed on an outer surface of a membrane, and a droplet of the liquid which is here are involved in a cell owing to emboly of a membrane inside between microvillis of a brush border with formation of a vacuole. Pinotsitozny vacuoles otshnurovyvatsya and move towards a basal part of a cell, in perinuclear area where there is Golgi's complex (see. Golgi complex ), they can merge with lysosomes which have high activity of a number of hydrolases, in particular acid phosphatase. The formed amino acids and low-molecular fragments of protein are selected through a basal membrane in blood.

In cells of renal tubules there are specific mechanisms for a separate reabsorption of various proteins — albumine, hemoglobin. Proteinuria (see) it is observed at a row fiziol, states, at a heavy exercise stress (a mid-flight albuminuria), upon transition from horizontal to vertical position (an orthostatic albuminuria), increase in venous pressure.

Secretion of organic acids and bases. In implementation of excretory function P. the important place belongs to secretion from pericanalicular liquid in a gleam of proximal department of nephron organic to - t — a paraaminogippurata (PAGE), penicillin, streptocides, furosemide, etc., and also organic bases (sincaline, guanidine, Tolazolinum, etc.). Most intensively secretion happens in a direct renal tubule of proximal department of nephron. Systems of secretion organic to - t and the bases function independently and are characterized by kinetics of saturation. E.g., after introduction PAGE in blood it is filtered in renal balls, and the rest with a blood flow comes to pericanalicular capillaries and diffuses in intercellular liquid. In basolateral cell membranes there is a carrier capable to form a complex with organic to-tami and to transport them in a cell. On the interior of a membrane the carrier releases in PAG cytoplasm, and itself is returned to an exterior surface of a membrane. PAGE moves on a cell in the direction to an apical membrane and by means of other carrier overcomes it and comes to a gleam of a renal tubule. The quantity of carriers organic to - t in a membrane is limited, and they have a certain speed of a turn; the maximum size of secretion PAGE is reached when its concentration in a blood plasma is sufficient for saturation of all carriers and is standard size. At numerous introduction PAGE and others organic to - the t cosecreted in renal tubules amplifies their transport cells of tubules owing to protein synthesis, necessary for secretion. Secretion of organic acids (e.g., PAGE) changes at various states. The maximum secretion PAGE decreases at a glomerulonephritis, an addisonovy disease, a nephrotic syndrome, an idiopathic hypertensia, a circulatory unefficiency and increases at anemia at children, cirrhosis (without ascites), a hyperpituitarism, a gipertireoidiz-ma. Intensity of allocation with urine weak to - t and the bases substantially depends on pH of canalicular liquid. At shift of pH in the acid party dissociation to - t decreases, and not ionized forms are soaked up through cellular membranes better; the bases reabsorbirutsya quicker from alkalinuria.

Reabsorptions of substances in distal department of nephron and collective renal tubules. In the thin descending department of a nephronic loop only water thanks to high osmotic permeability of this tubule can be soaked up. The thin ascending department of a nephronic loop badly pronitsay for water, but its wall of a pronitsayem for urea, sodium and chlorine. The intensive reabsorption of salts through a wall, impenetrable for water, begins in the thick ascending department of a nephronic loop. Distinctive feature of this tubule is existence of positive potential from a gleam of a tubule. Cells of this tubule have high activity of Na-, K-ATP-ase. There is still not clear a ratio of cellular and membrane mechanisms of a reabsorption of sodium and chlorine in this department of nephron. Here potassium, calcium, magnesium reabsorbirutsya and though the total amount of the soaked-up liquid in this tubule small because of low-permeability for water, in it can reabsorbirovatsya to 20 — 25% of the filtered ions of sodium and potassium. From the thick ascending department of a nephronic loop in distal gyrose the tubule arrives hypotonic liquid. Through a waterproof wall of this tubule about 10% of the filtered sodium due to activity of Na-, K-ATP-ase reabsorbirutsya, ions of chlorine follow passively on a gradient to elek-trokhy. potential, the potential difference in this tubule reaches 30 — 60 mV. Concentration of sodium in a gleam of a gyrose tubule of distal department of nephron decreases to 40 — 30 mmol/l, its cells reabsorbirut potassium ions, calcium, magnesium, etc. In a binding part of nephron and collective renal tubules only 1 — 2% of the filtered sodium reabsorbirutsya, but these departments of tubules are capable to transport ions against a high electrochemical gradient, and at deficit of salts urine with very low concentration of ions is excreted. Cells of final parts of a distal gyrose kanalp, binding part and collective renal tubules are the main scene of action of Aldosteronum and antidiuretic hormone.

Secretion of potassium. The filtered potassium almost completely reabsorbirutsya in nephron, and cosecreted by cells of distal departments of nephrons — is excreted with urine. In the same cells of a distal gyrose tubule and a collective renal tubule, on - vidi-momu, systems of a reabsorption and secretion of potassium function. At a reabsorption potassium is soaked up through an apical membrane, passes in cytoplasm and is removed through basolateral membranes. At secretion potassium comes to cytoplasm through basolateral membranes from intercellular liquid by means of Na-, K-ATP-ase in exchange for reabsorbiruyemy ions of sodium. High potassium concentration in cytoplasm creates conditions for its secretion in a gleam of a tubule. Speed of secretion of potassium depends on permeability of an apical plasma membrane for potassium, intensity of accumulation of potassium in a cell (sodium - the potassium pump), a gradient of electric potential on a membrane, through to-ruyu cosecretes potassium, increases in electronegativity of liquid in a gleam of a tubule in the presence in it the anions which are badly getting through a membrane, napr, sulfate.

Osmotic cultivation and concoction of urine. In proximal department of nephron from 75 to 80% of an ultrafiltrate are soaked up. The remained liquid passes into the thin descending part of a nephronic loop. Considerable differences are found as a part of intercellular and canalicular lymph in marrow P. at extreme conditions of a water balance — an overhydratation and dehydration. In comparison with a water diuresis during the anti-diuresis caused by dehydration or an injection of antidiuretic hormone, concentration of osmotically active agents at top of a renal nipple becomes several times higher; osmolarity of the urine emitted at this moment is practically leveled with osmotic strength of fluid in marrow P. The main osmotically active agents in the deepest nephronic loops are ions of sodium, chlorine and urea. In a kidney formation of urine, hypertensive in relation to blood, happens in such a way that water at all stages of an uropoiesis moves only passively on an osmotic gradient.

For osmotic concoction of urine i.e. in order that from a gleam of a collective renal tubule in surrounding intersticial fabric water without simultaneous absorption of the corresponding amount of osmotically active agents was soaked up, it is necessary that in the intersticial fabric surrounding a tubule osmotic pressure was higher, than osmotic pressure in a collective renal tubule, and its wall would be a pronitsayema for water and is impenetrable for salts. In marrow P. osmotic concentration is higher, than in cortical substance P. Gradual increase of an osmotic gradient in the direction from cortical substance to top of a renal nipple is caused by activity of all structures of marrow (tubules and vessels) as counter-current rotary multiplying flow system. The descending and ascending parts of a nephronic loop are connected with each other by loops of a capillary network which like bridges connect them in a uniform functional complex.

In an outside zone of marrow the leading role in ensuring osmotic concoction of urine is played by transport of chlorine and sodium cells of the ascending (thick) part of a nephronic loop. When liquid from proximal department of nephron comes to the thin descending part of a nephronic loop, it gets to an outside zone of marrow P., in intersticial fabric a cut concentration of osmotically active agents is higher, than in cortical substance P. This increase in osmolyarny concentration is caused by activity of the thick ascending part of a nephronic loop, a cell to-rogo actively transport in intersticial fabric ions of chlorine and sodium without water. Since the wall of the descending part of a loop, unlike the thick ascending part, a pronitsayem for water, but not for ions, water passes from its gleam into surrounding intersticial fabric on an osmotic gradient. Osmolyarny concentration increases in intersticial fabric of this area, at the same size also osmolyarny strength of fluid, the descending part of a loop which is in a gleam increases. It is caused by the fact that through a water-permeable wall water while osmotically active agents remain in a gleam of this tubule passes into an interstitium on a gradient.

The further from cortical substance on a longitudinal axis of a renal nipple investigate liquid in the descending part of a loop, the higher it osmolyarny concentration. Thus, in the neighboring sites of the descending part of a loop only small increase of osmotic pressure is noted, but towards a renal nipple osmolyarny concentration gradually grows from 300 mosm/l and probably reaches at the person of 1500 mosm/l.

The mechanism of osmotic concoction of urine in an internal zone of marrow of a kidney remains not clear. The model is offered, according to a cut in an internal zone of marrow only passive processes provide osmotic concoction of urine. The thin descending part of a nephronic loop has very much high-permeability for water and low-permeability for ions of sodium, chlorine and urea (fig. 6). The thin ascending part of a nephronic loop is waterproof, but a pronitsayema for sodium chloride and to a lesser extent for urea. At an anti-diuresis in comparison with a water diuresis concentration of osmotically active agents in an internal zone of marrow sharply increases. It, apparently, depends on increase in a reabsorption of urea, its inclusion in counterflow exchange and accumulation in marrow. In proximal department of nephron the wall of a pronitsayem for urea, and in it is exposed to the return absorption more than 50% of the filtered urea. However at the beginning of distal department of nephron the content of urea even exceeds its quantity arriving with a filtrate a little and makes apprx. 110%. It is caused by existence of system of an intra renal circulation of urea. In a gleam of the thin ascending part of a nephronic loop diffuse large amounts of urea while liquid flows in this tubule in an internal zone of marrow P. The wall of the subsequent departments of nephron and cortical parts of collective renal tubules is impenetrable for urea again. Only in collective renal tubules of an internal zone of marrow of a kidney antidiuretic hormone increases permeability of a canalicular wall not only for water, but also for urea, diffuses edges on a gradient in intersticial fabric. It promotes sharp increase of osmolarity of marrow of a kidney in which urea makes a half of concentration of osmotically active agents.

Function of a kidney on maintenance of water-salt balance is inseparably linked with its participation in osmoregulation, a volyumoregulyation, stabilization of ionic composition of liquids of internal environment (see. Water salt metabolism ). Constancy of volume of liquid in an organism is caused by regulation of allocation of P. of water and sodium salts for what also incretory function P., secretion in blood has essential value renin (see) and prostaglandins (see). P.'s role in osmoregulation (see. Osmotic pressure ) is defined by a possibility of separate regulation of allocation a kidney of water and ions. At excess of water in P.'s organism emits urine with low concentration of osmotically active agents; salts are soaked up by cells of renal tubules and excreted excessive an amount of water. On the contrary, at hyper osmolarity of blood for decrease in its osmotic pressure in P. water reabsorbirutsya, and osmotically concentrated urine is formed, desalting of blood is as a result reached. The possibility of an independent reabsorption of separate ions allows P. to regulate under the influence of a nervous system and hormones concentration of each of ions in blood. At excess intake of salts in an organism these ions are excreted by P., ionic is provided homeostasis (see). Secretion of hydrogen ions and ammonia is the cornerstone of P.'s activities for regulation acid-base equilibrium (see).

P.'s participation in maintenance of a stable pH value of blood is connected with P.'s ability to excretion of surplus to - t and the bases depending on the situation which developed in an organism. Cells of proximal department of nephron cosecrete H+ in a gleam of a tubule in exchange for reabsorbiruyemy ions of sodium. In a gleam of a tubule of H+ connects to HCO-and H2CO3 is formed, edges under the influence of a karboangidraza breaks up to CO2 and H2O. In a cell through a membrane diffuses CO2, and in cytoplasm with the participation of a karboangidraza it is hydrated with formation of H2CO3 dissociating on HCO 3 - soaked up in blood through a basolateral membrane after sodium, and H+ cosecreted in a gleam of a tubule. This continuously proceeding process leads to a reabsorption in a gyrose renal tubule of proximal department of nephron more than 90% of NSOG and the related sodium. In a nephronic loop the most part of nereabsorbirovanny HCO is soaked up 3 -  ; 1 — 4% it reaches a gyrose tubule of distal department of nephron. In this tubule and collective renal tubules secretion of H+ continues, edges promotes transformation of HPO 4 2- in H 2 PO 4 - and to absorption of equivalent amount of sodium. Water can be a source of H+, IT is group a cut under the influence of a karboangidraza provides formation of HCO 3 - from CO2.

In cells of renal tubules there is a deamination of amino acids, and first of all a glutamine, under the influence of a glutaminase; NH3 diffuses in a gleam of a tubule, connects to H+, and the ion of ammonium replaces reabsorbiruyemy sodium. Usually the person has a total quantity cosecreted H+ connected with secretion of ammonium and allocation titrated to - t, makes 50 — 70 mmol a day, but at acidosis it can increase up to 500 mmol. In comparison with a normal amount of pH of blood (apprx. 7,4) concentration of H+ can increase in urine almost by 1000 times, and pH of urine decreases to 4,4 that allows to change over a wide range allocation of H+ in urine, stabilizing pH of blood. At an alkalosis of pH of urine increases to 8,0 since P. begin to excrete bicarbonates.

Excretory function

P. plays the leading role in allocation from blood of nonvolatile end products of exchange, alien substances which got to internal environment of an organism. With urine also a number of the substances which are contained in usual conditions in it in trace quantities and many methods not found, napr, glucose, amino acids can be allocated; the most part of these threshold substances is soaked up in renal tubules, but when there is their surplus in blood, systems of absorption are sated, and such substances begin to come to urine in a large number. The strengthened excretion of these substances is observed in the conditions of pathology and at the normal content in blood when work of the cells which are soaking up them is broken.

Items play an important role in excretion of products of a nitrogen metabolism, first of all urea (see) and uric acid (see). Urea is filtered in renal balls, partially soaked up, and other quantity (to 30 g a day) is removed with urine. Uric to - that is filtered in renal balls, to 90 its % reabsorbirutsya, and a significant amount at the same time cosecretes. Strengthening uric to - you in blood can be a consequence of high speed of its synthesis, decrease in glomerular filtering, strengthening of a canalicular reabsorption or decrease in secretion of uric acid.

Creatine phosphoric to - that is one of the most important components of muscle cells. After eliminating of phosphate from it creatine is formed, as a result of dehydration of a molecule to-rogo creatinine is formed. Daily products of creatinine are enough constant, it depends not so much on the maintenance of meat in food how many from the muscle bulk of a body. The important factors determining the level of products of creatinine are the sex, age, extent of development of muscles, metabolic rate; on average in days it is formed and excreted with urine of 1,8 g of creatinine. As creatinine comes to a gleam of nephron of hl. obr. in renal balls, and in days 180 l of a blood plasma with concentration of 10 mg/l are filtered, daily excretion is equal to 1,8 g. At various people concentration of creatinine in a blood plasma fluctuates from 0,7 to 1,3 mg / 100 ml. Daily release of creatinine changes a little therefore at reduction of glomerular filtering concentration of creatinine in proportion increases in a blood plasma.

Items delete from an organism or split the most various substances therefore at a heavy renal failure in blood various organic matters collect (urea, creatinine, methyl guanidine, guanidine - amber to - that, gastrin, tsAMF, indoles, phenols, glucuronic to - that, beta 2 - microglobulin, a lipochrome, pancreatic polypeptide, a lysozyme, etc.).

Some pharmacological means break transport of uric acid in renal tubules and reduce its excretion kidneys. Alien substances are emitted to P. by means of filtering in renal balls and secretion with cells of an epithelium of renal tubules.

Endocrine function

In P. physiologically active agents possessing systemic and local action are produced — renin (see), erythropoetin (see), an active form of D3 vitamin (see. Kaljtsiferola ), prostaglandins (see), bradikinin (see. Mediators of allergic reactions ). Formation of the renin which is proteolytic enzyme happens in the juxtaglomerular device; more than 90% of the granules containing a renin are in cells of a wall of the bringing glomerular arteriole. Secretion of a renin increases at reduction of a krovenapolneniye of the bringing glomerular arteriole and strengthening of sodium chloride in distal department of nephron in the field of a dense spot (macula densa). Allocation of a renin in both cases thanks to vasoconstrictive effect of angiotensin (see) promotes reduction of excretion of sodium and water a kidney and to preservation of volume of blood. The renin chips off from the angiotensinogen which is in fraction alpha 2 - globulin, the angiotensin I consisting of 10 amino acids. In a blood plasma under the influence of the turning enzyme from angiotensin I two amino acids are chipped off and angiotensin II which possesses the expressed vasoconstrictive action is formed. It regulates a reabsorption of sodium in renal tubules and increases secretion of Aldosteronum bark of an adrenal gland, stimulates secretion of vasopressin, activates the center of thirst, oppresses secretion of a renin in a kidney. Angiotensin II can turn into the angiotensin III possessing high biol, activity. The inactivation of angiotensin occurs very quickly; speed of metabolic clearance of angiotensin II at the person is equal to 2,2 l in 1 min.

P.'s cells remove from blood the pro-hormone 25-(OH) which is formed in a liver - D3 vitamin and as a result of a hydroxylation turn it in 1,25-(OH)2 D3 vitamin which stimulates absorption of calcium in intestines, promotes a mineralization of bones, participates in regulation of a reabsorption of calcium and inorganic phosphate in renal tubules.

In P. the plasminogen activator — an urokinase is also synthesized. The item cosecretes peptidase — kallikrein which chips off kinin from a kininogen. In marrow P. a number of prostaglandins, including E2 and F2 is formed. E2 prostaglandin strengthens P.'s blood stream, increases release of sodium, apparently, oppressing a reabsorption of sodium and water in a proximal tubule. Activity 15 oxydehydrogenases, inactivating prostaglandins, is highest in cortical substance of kidneys. Items are the place of formation of erythropoetin — the glycoprotein stimulating an erythrogenesis in marrow.

Metabolic function

In P. there are not only filtering and a reabsorption, but also splitting and protein synthesis, lipids and carbohydrates. The changed proteins, peptides, including peptide hormones which are hydrolyzed in cells of a tubule of proximal department of nephron can come to a gleam of the capsule of a ball during filtering, and in blood amino acids and oligopeptida are soaked up. That P. promote recovery of fund of amino acids and an inactivation of physiologically active agents.

In the course of metabolism on energy expenditure in P. are used neesteri-fitsirovanny fat to - you and glucose. P.'s contribution to a homeostasis of carbohydrates, and especially glucose, depends on a ratio between filtering and a reabsorption of the filtered glucose, its uses in P. V usual conditions the speed of utilization and synthesis of glucose in P. is almost identical to development of energy and a gluconeogenesis; synthesis of glucose in it comes from substrates with shorter chain and from fructose. At optimal conditions in cortical substance P. the speed of formation of glucose can exceed its utilization by 10 times. Ability to a gluconeogenesis is characteristic of cortical substance P., in marrow intensively proceeds glycolysis (see). At long starvation due to neoglucogenesis in cortical substance P. a half of total quantity of the glucose coming to blood is formed. In the conditions of acidosis the gluconeogenesis from those predecessors who participate in education oxalacetic to - you grows in P. that has obvious homeostatic value: contributes to normalization of pH of blood; at an alkalosis the speed of a gluconeogenesis at the expense of acid substrates decreases. P.'s role in carbohydrate metabolism was underestimated though intensity of a gluconeogenesis on 1 g of cortical substance of a kidney is higher, than in a liver. The possibility of selective activation of enzymes of a gluconeogenesis only in P. (at acidosis activity of a fosfofenolpiruvatkarboksi-kinase increases in cortical substance of a kidney) is shown, in a liver activity of this enzyme does not change. In P. the phosphatidylinositol necessary for creation plasmatic mekhmbran is synthesized. P.'s role in lipidic exchange consists in utilization free fat to - t, formation of triatsilglitserin.

Neyrogumoralnaya regulation of function of kidneys

Fig. 7. Scheme of participation of a kidney in regulation of a water salt metabolism. Information on a condition of a water salt metabolism comes to c. N of page from various types of receptors. Regulation of function of a kidney is carried out by means of efferent nerves, hormones of various closed glands, and also physiologically active agents which are formed in a kidney (angiotensin, prostaglandins).

Information from osmo-, volyumoretseptor and ionic receptors comes to c. N page, the corresponding nervous and humoral incentives create adequate behavioural acts, water and salt appetite changes, work of the effector bodies providing water-salt balance adapts. Depending on conditions in an organism removal of water and salts changes and the optimum structure of internal environment is provided. Regulation of allocation of P. of water is carried out by means of an osmoreguliruyushchy reflex which plays the leading role in regulation of water exchange (fig. 7). As afferent, sensitive element of system of osmoregulation serve osmoreceptors and probably the natrioretseptor which are available in various bodies and fabrics including in a liver and in a hypothalamus. At increase in osmotic concentration of blood these receptors are irritated and neurons of a supraoptic kernel are activated. In the terminations of axons of these cells in a back share of a hypophysis the arginine-vasopressin which is antidiuretic hormone is released in blood (see. Vasopressin ). This hormone with a blood flow reaches a kidney, the reabsorption of water in as a result increases in renal tubules, osmotic concentration of urine increases.

In normal conditions osmolarity of blood at the person fluctuates in very small limits. After drink of water it can decrease to 280 mosmol/l, at the same time secretion of antidiuretic hormone stops and the maximum water diuresis with osmotic concentration of urine lower than 100 mosmol/l develops. At dehydration osmolarity of blood and when it raises to 295 mosmol/l increases, secretion of antidiuretic hormone increases so considerably that the maximum of osmotic concoction of urine is reached. The person has an increase of osmolarity of blood for 0,3% — 1 mosmol/l is followed with the participation of antidiuretic hormone by increase in osmolarity of urine approximately on 95 mosmol/l.

Secretion of antidiuretic hormone occurs also at pain stimulation, introduction various pharmakol, means, napr, morphine, nicotine, and also at the bloodletting and other states which are followed by reduction of volume of the circulating blood. The system of regulation of volume of blood possesses two types of volyumoretseptor. One of them react to change of intravascular volume and are localized in a wall of a carotid sine (a sleepy sine, T.) and aortic arch. The receptors of a zone of low pressure localized in a wall of the left auricle and controlling inflow of blood to a left ventricle are more sensitive. At increase in inflow of blood to heart secretion of antidiuretic hormone decreases, and also nervous and humoral influences on P. regulating a reabsorption of sodium that promotes excretion of sodium and water and recovery of initial volume of blood change. At reduction of volume of intravascular liquid baroreceptors of a zone of high pressure are activated, secretion of ADG is stimulated, Aldosteronum (see), locally secretion of a renin increases in a kidney. All this leads to strengthening of a reabsorption of water and salts and recovery of volume of blood and extracellular liquid. In maintenance of functional capacity of a kidney to excretion of large volumes of liquid

are important glucocorticoid hormones (see) and Aldosteronum which stimulate a reabsorption of sodium and chlorine.

Regulation of release of sodium P. cannot be explained only with action of Aldosteronum and change of glomerular filtering. Apparently, there is still the third factor, or as it is often called, natriuretic hormone which strengthens a natriuresis. The substances having high natriuretic activity are emitted from urine of the person after salt loading.

Items are important effector body of system of ionic regulation. In an organism there are reflex systems of regulation of exchange of a number of ions, in nek-ry cases of a cell of closed glands directly react to change of concentration in blood of the corresponding ion. Aldosteronum strengthens secretion of potassium in distal department of nephron and collective renal tubules; this action is not connected with its influence on a reabsorption of sodium. Insulin reduces release of potassium P. In addition to nervous and humoral factors, its concentration in pericanalicular liquid has significant effect on the level of excretion of potassium. At alkalosis (see) release of potassium P. amplifies, and at acidosis (see) decreases.

The calcium arriving with food in the course of absorption promotes secretion went to blood of hormones. - kish. a path which stimulate a pas-rafollikulyarnye of a cell (near - follicular tirotsita) a thyroid gland and in blood it is allocated tirokaltsitonin. The calcium which is soaked up in intestines comes to the general blood stream, and its surplus also activates allocation in blood calcitonin (see), having Hypaque altsiyemichesky and hypophosphathat-chesky effect and strengthening excretion of calcium ions and phosphates P. Introduction to an organism parathormone (see) is followed by reduction of release of calcium and strengthening of excretion of phosphates. Preservation of phosphates in an organism, increase in their reabsorption comes under the influence of a growth hormone; 1,25-(OH)3 D3 vitamin and parathormone increase a reabsorption of calcium in distal department of nephron. In usual conditions 1,25-(OH)2 - Vit - min. D3 increases a reabsorption of phosphates.

For many years the question of a role of nervous control of function of renal tubules was actively discussed. In the 50th 20 century there was an opinion that efferent nerves do not play an essential role in regulation of secretion and a reabsorption of the main components of urine. Further the evidence of stimulation of a reabsorption of salts and water in a tubule of proximal department of nephron under the influence of efferent nerves of P. in the absence of any shifts of a hemodynamics and glomerular filtering were obtained. These changes of canalicular transport are caused by a direct impact of mediators, but not caused by action of physical forces and the circulating humoral agents. There is not clear a ratio between nervous and hormonal influences, and also a role of numerous receptors and esodic nerves in regulation of function P.

Change of function P. iod influence of hormones and mediators is caused not by direct effect of these substances on the relevant structure of P., and includes a row intermediate biochemical, reactions. In an experiment introduction of Aldosteronum to adrenalectomized rats recovers a reabsorption of sodium in proximal and hl. obr. in distal departments of nephron, cortical departments of collective renal tubules. From a blood plasma Aldosteronum gets into intercellular liquid, passes through a plasma membrane in cytoplasm of a target cell, in a cut primary linkng of hormone with stereospecific protein is carried out, and this complex is transported in a kernel (apprx. 600 molecules of Aldosteronum communicates a kernel of a cell of a renal tubule). Aldosteronum induces formation of several RNA types in a kernel, with participation to-rykh a ribosome carry out synthesis of several types of the proteins necessary for change funkts, activities of a cell. As a result Aldosteronum increases a reabsorption of sodium, increasing sodium permeability of an apical membrane and power of sodium pompes of a cell.

Action of Aldosteronum on transport of sodium and potassium is provided with independent cellular mechanisms; influence on secretion of potassium cells of distal department of nephron, apparently, is defined by increase in potassium permeability of the plasma membrane turned into a gleam of a tubule, and strengthening of accumulation of potassium in a cell owing to activation sodium potassium pump in a basal plasma membrane. Vasopressin, parathormone from a vascular bed get into intercellular liquid and reach basal membranes of target cells. On an exterior surface of these cells there are receptors specific to each of these hormones and connected with enzyme adenylatecyclase. This enzyme is localized on an inner surface of a plasma membrane, and after interaction of hormone with a receptor is activated to adenylatecyclase, under its influence tsAMF which serves as the intracellular intermediary changing functional activity of a cell is formed of ATP. A part of tsAMF is inactivated by enzyme phosphodiesterase of a cyclic nucleotide, partially tsAMF gets through an apical cell membrane into urine.

In cells of various departments of nephron different sensitivity of adenylatecyclase to various hormones is observed. Receptors for parathormone in P. are available in cells of proximal department of nephron, the thick ascending part of a nephronic loop and distal department of nephron, the greatest activation of adenylatecyclase this hormone is characteristic of initial parts of a gyrose tubule of distal department of nephron. The calcitonin activates adenylate - cyclase in cells of the thick ascending part of a nephronic loop and initial parts of distal department of nephron, vasopressin — in final parts of distal department of nephron and collective renal tubules. The possibility of reaction of a cell of the same department of tubules to hormones with opposite influence on exchange of calcium — parathormone and a calcitonin demonstrates existence of the tsAMF independent intracellular funds and ways of implementation of their effect.

TsAMF formed in basolateral cell membranes moves towards an apical plasma membrane, in a cut there is a protein kinase. Under the influence of tsAMF this enzyme dissociates that eventually leads to increase in osmotic permeability of a wall of collective renal tubules. The simple scheme of regulation of intracellular processes (hormone — the second intermediary of tsAMF — physiological reaction of a cell) does not reflect completeness of the picture which is developed after interaction of a receptor of an outer plasma membrane with hormone or a mediator. After activation of adenylatecyclase and formation of tsAMF concentration in a cell of calcium ions, etc. changes that models effect of hormone. In this regard prostaglandins are of great interest. In P., and it is possible also in the same cell, napr, a collective tubule, ADG activates adenylatecyclase, formation of tsAMF and, on the other hand, stimulates a phospholipase and formation of prostaglandins. Prostaglandin of Ekh in very low concentrations reduces ability of ADG to increase permeability for water of collective tubules. Prostaglandins are probably one of natural regulators of cellular effect of vasopressin, serve as an important element of system of a feed-back, with the help a cut it is possible to change reactivity of a cell to this hormone, to counteract overshot effect of ADG.

As a result of the intracellular biochemical processes caused by ADG and connected with participation of tsAMF reaction joins microtubules and microfilaments, there is an aggregation of particles, secretion of hydrolases is activated and eventually permeability of a canalicular wall for water increases. It agrees one of hypotheses, increase in osmotic permeability is connected with increase in number of hydrophilic channels in an apical plasma membrane of a cell. In 1958 A. G. Ginetsinsky stated a hypothesis, according to a cut of ADG stimulates secretion of hyaluronidase with cells of tubules, the depolymerization hyaluronic to - you is caused and permeability for water increases. The increase in water flow caused by ADG on an osmotic gradient is followed by expansion of intercellular intervals, except a zone of cellular contacts. Introduction of antibodies to hyaluronidase P. reduces effect of antidiuretic hormone. The problem of a role of a cell and intercellular substance in increase in water flow remains debatable.

Age features of function of kidneys

the Organism of a fruit entirely is under protection of homeostatic mechanisms of mother though to the end of pregnancy of its P. form hypotonic urine. Function P. at children in the period of a neonatality are characterized by the low size of glomerular filtering, limited opportunities of concoction and cultivation of urine, weak ability to develop an osmotic diuresis and to reabsorbirovat anion of a hydrocarbonate. The low size of glomerular filtering is caused by a limited filtering surface, low-permeability of membranes, low hydrostatic (arterial) pressure and considerable resistance to a blood-groove in the bringing vessels.

N. P. Gongdobing and sotr. (1906) it was established that the filtering membranes at newborns are thicker to what adults, loops of glomerular circulatory capillaries are covered with a cubic and cylindrical epithelium which is transformed further to flat. At newborns heterogeneity of a structure of nephron is noted. Variations of diameter and an arrangement of renal balls, a backwardness of superficially located nephrons are noted.

In the first weeks of life the filtering surface of renal balls is about 5 times less, than at the adult. Age changes of glomerular filtering at children are caused by development of surface nephrons of cortical substance of kidneys, and also glomerular circulatory capillaries, increase in a blood-groove through capillaries, at the same time filtering increases though filtrational pressure remains in the course of growth to constants.

The size of glomerular filtering counting on a standard body surface (1,73 sq.m) reaches the same values as at adults, at the age of 6 months and it is stabilized at this level at most of children on the second year of life. The limiting factor of filtrational process at early children's age is immaturity of canalicular systems, but not renal balls as it was considered earlier. In the course of growth of the child balance between amount of the filtered plasma and ability of renal tubules to reabsorbirovat or cosecrete electrolytes, water, organic compounds (glomerulotubulyarny balance) gradually is established.

Canalicular transport systems of newborns function in limits fiziol, opportunities, and adaptation of renal functions to loadings is carried out through changes of filtering and to a lesser extent — by means of neuroendocrinal influences on systems of active transport in renal tubules. In the course of growth of the child diameter of gyrose renal tubules of proximal departments of nephron, to a lesser extent — their length increases. Distribution of activity of Na-, K-ATP-ase in nephron does not change with age though its activity increases, especially in gyrose tubules of proximal departments of nephrons.

At newborns sensitivity of adenylatecyclase of renal tubules to vasopressin, parathormone is reduced; sensitivity of a canalicular epithelium to Aldosteronum at the birth also low and gradually increases in process of growth of the child.

In development of renal tubules their sensitivity to effect of hormones increases and the range of adaptive reactions extends. However, as well as increase in weight of P., development of their functions is not in linear relation from age, the periods of acceleration of development alternate with the periods of delay. The maximum canalicular secretion PAGE, extremely low at newborns, reaches indicators of adults on the second year of life, with age also the clearance PAGE similarly changes.

Maximum canalicular reabsorptions of glucose at newborns counting on a body surface of the adult are made by 60 mg/min., at children of chest age — 170, at children up to 14 years — 304, adults have 303 — 375 mg/min. The melituria of children of early age is connected with immaturity of canalicular systems of a reabsorption of glucose and other carbohydrates.

By means of test on concoction it is established that both the full-term, and premature newborns emit urine, the maximum osmotic concentration does not exceed a cut 650 mine. Ability to concentrate urine in the conditions of restriction of liquid is improved approximately in the second half of the year of life.

Development of concentration ability of P. in children is accompanied by the increasing sensitivity to effect of antidiuretic hormone of the adenylatecyclase of renal tubules providing synthesis of cyclic 3,5-AMF (tsAMF).

Items of newborns are capable to cultivation of urine and removal of a large amount of liquid if it is entered not in one step, and is fractional. Ability to remove surplus of hydrogen ions develops in the first weeks of life. In the period of a neonatality it is limited owing to the low size of glomerular filtering (insufficient receipt in renal tubules of buffer phosphates) and lower threshold of renal excretion of anion of a hydrocarbonate. If at adults this threshold makes 25 — 28 mmol/l, then at newborns it does not exceed 22 mmol/l. It is caused by insufficiency of fermental systems of secretion of hydrogen ions and transport of anion of a hydrocarbonate (HCO 3 - ) in tubules of proximal departments of nephron in this connection P. do not provide economy of hydrocarbonates. At the same time mechanisms of an ammoniogenesis are well developed already by the time of the birth. According to age features of function of nephron there is also a sensitivity of a children's organism to effect of diuretics.

Each age period is characterized by compliance funkts, P.'s conditions to requirements of the growing organism. However this compliance is defined also by conditions of a water relationships, feeding and food, deviations to-rykh lead to disturbances of nitrogen and water-salt equilibrium. For removal of equivalent amounts of osmotically active agents P. of the child demands more water, than P. of the adult.

Considerable part of protein and salts is late in the growing organism that reduces osmotic load of the Item. Functional insufficiency of P. arises at restriction of water, increase in a diet of the salts and substances which are subject to removal by kidneys (artificial feeding) and also at delay and the termination of growth.

The acute renal failure at children develops at the beginning of acute inf. diseases, at intoxications or injuries also differs in more favorable forecast, than at adults. The acute renal failure in the period of a neonatality is shown by the anury lasting more than 48 hours after the birth. Heavy asphyxia, thrombosis of renal veins, an urate heart attack, malformations of kidneys and uric ways, an inborn hydronephrosis, a multicystosis and tumors of kidneys, spinal hernia can be its reasons.

In development hron, a renal failure, along with a diffusion glomerulonephritis and pyelonephritis, the significant role is played by inborn and hereditary diseases of P. and a metabolism.

A renal blood stream and a plazmotok, glomerular filterings, the maximum ability to a reabsorption of glucose and secretion PAGE during the calculation at a standard size of a body surface (1,73 m 2 ) remain without changes up to 45 — 50 years then there is a slow decrease in these indicators. The Effective Renal Plazmotok (ERP) decreases aged 40 years almost on 250 ml are more senior (size EPP can be calculated by a formula: EPP — 840 — 6,44*chislo years). Glomerular filtering for the same term decreases almost by 40 ml/min., its falling after 40 years is characterized by the equation: 153,2 — 0,96 * number of years. The reason of reduction of a renal blood-groove and glomerular filtering, apparently, are sclerous change in vessels and gradual involution of renal balls. The reduction of glomerular filtering and secretory ability of P. occurring with age should be considered at prescription of medicines since their removal from blood P is slowed down. Osmotic concoction of urine decreases at advanced age. It is caused by change of activity of P. since at this age sensitivity of osmoreceptors and Gipotalamo-Gipofizarnaya system is higher cosecretes more vasopressin on introduction of the same amount of osmotically active agents, than aged up to 50 years. Consider it as compensatory reaction to reduction of ability of P. to detain water in an organism. Depression of function of osmotic concoction depends on a variety of reasons — increase in a blood-groove in marrow P. and the washing away of osmotically active agents caused by it from marrow and decrease in overall performance of a counter-current flow system, reduction of glomerular filtering, change of a condition of intersticial fabric, etc. Age changes are noted also in regulation of sodium exchange. They depend on decrease in glomerular filtering, a renal plazmotok, changes of influences renin-angiotensin-is scarlet dosteronovy system. Features of participation of P. in water and sodium exchange at advanced and senile age matter in developing of hypostases, hypertensia, etc.

Experimental methods of a research of function of kidneys

Functions P. at not plank beds-kotizirovannykh a lab. animals are studied by means of operation of imposing of a fistula of a bladder on I. P. Pavlov's method or separate removal of mouths of ureters at dogs on skin of an abdominal wall by L. A. Orbeli's method. In this case it is possible to denervate one P. or to catheterize a renal artery, to enter biologically active agents and to differentiate their local and cumulative effects on function P. In experiences on a lab. animal in vivo and during the studying of Separate pochech-nykhzhanalets measure a glomerular filtration rate on clarification from inulin, Mannitolum, polietilengliko la-1500, creatinine; a renal plazmotok — on clarification from PAGE or Diodrastum; maximum reabsorptions in a gyrose renal tubule of proximal department of nephron the maximum secretion in the same department of a tubule — on the help PAGE or Diodrastum decides on the help of glucose. Formulas and conditions of carrying out researches are developed, at to-rykh osmoreguliruyushchy function P., a reabsorption of separate ions in proximal and distal departments of nephron is estimated. For definition of localization of transport of substances in renal tubules a certain role was played by a method of the so-called stopped mocheotdeleniye. Its essence is that to an animal enter hypertensive solution of Mannitolum and against the background of very high osmotic diuresis for several minutes stop a mocheotdeleniye, pressing the catheter entered into an ureter. Pressure in renal tubules at the same time quickly increases that counteracts glomerular filtering. In each of departments of nephron liquid contacts longer to cells which continue to perform usual functions on transport of substances at secretion and a reabsorption. Then liquid is quickly produced from an ureter and collect consecutive tests of urine. Tests of the liquid which was in distal department of nephron judge on the minimum concentration of sodium, in proximal department of nephron — on the maximum secretion PAGE, determine emergence of a new portion of a glomerular filtrate by test, in a cut there was an inulin entered at the end of the period of the stopped mocheotdeleniye.

Big distribution in experimental physiology of a kidney was gained by various options of micropuncture methods. By means of a micropipet remove liquid from various departments of renal tubules and subject to the subsequent ultramicroanalysis. At simultaneous introduction of two pipettes to various sites of one nephron it is possible to perfuse a tubule liquid of the famous structure and to measure the speed of a reabsorption of the entered substance. Determine the speed of a reabsorption of various substances in a tubule of proximal department of nephron by the halved droplet of oil. For a research of the departments of nephron unavailable to a micropuncture, the method of microperfusion of the isolated tubules is developed. For studying of influence of the pericanalicular environment on function of renal tubules at the same time carry out microperfusion of the post-glomerular capillaries forming a vokrugkanaltse-vy capillary network and the corresponding renal tubule. Apply the selection microelectrodes to definition of ion activity in cells of renal tubules and intra canalicular liquid, and also microelectrodes for elektrofiziol. researches of renal tubules.

For functional and biochemical, characteristics of membranes of cells of L. apply the methods of elektroforetrshesky division allowing to allocate separately enough apical and basolateral membranes. The analysis of element structure of cells of various departments of nephron and the ultramicroanalysis of the tests received at a micropuncture carry out by method of the X-ray microanalysis.

The important place during the studying of the mechanism of effect of hormones, biologically active agents and cellular mechanisms of transport of ions is occupied by experiences on biol, the objects which are functionally reminding final departments of renal tubules, napr on the isolated leather and a bladder of toads and frogs. These objects at a research of hormonal regulation of transport of water and sodium have special value. Nek-roye distribution was gained by a method of studying of functions of the isolated kidney, however at the same time there are difficulties connected with the fact that it is not possible to support its long time in a full-fledged functional state.

METHODS of INSPECTION

Clinical physicians have a large number of the methods allowing to establish anatomo-funktsional-noye P.'s condition, to diagnose a specific disease of P., weight of its current for this patient, to define extent of compensation of functional systems of an organism, to reveal complications and extent of mutual burdening of the basic and associated diseases. The volume of researches P. depends on where they are carried out — in policlinic, a hospital, sanatorium or other conditions, and also from what aim they pursue — diagnosis, control of the course of treatment, dispensary observation.

Inspection of the patient is begun with clarification of its complaints, collecting the anamnesis of a disease and life, survey, a palpation, percussion, auscultation in combination with laboratory, tool, radiological, tracer and other techniques.

Important diagnostic value has detailed studying of complaints of the patient. Irrespective of character of complaints (pains, hypostases, frustration of a mocheotdeleniye, etc.) in each case character and time of their emergence and feature of manifestation establish, give them the quantitative and qualitative characteristic, establish the reasons causing them, and the phenomena, to-rymi they are followed. The complaints characteristic of renal colic (see. Nephrolithiasis ), on a gross hematuria (see. Hamaturia ), oliguria (see), anury (see), polyuria (see) or nocturia (see), speeded up and urodynias can meet at various diseases of the Item. During the collecting the anamnesis special attention is paid to studying of an onset of the illness, features of its manifestation and a current. It is important to know when for the first time there was a disease and as often it recured. At inquiry specify communication between P.'s diseases and other diseases (tuberculosis, quinsy, a hypertension, etc.). Carefully collect the family anamnesis, reveal hereditary diseases (a nephrogenic not diabetes mellitus, a family Cystinuria, a renal glucosuria, various genetic a nephropathy).

Studying the patient, mean that young women have pyelonephritis (see) much more often, than men that at men the frequency of pyelonephritis increases in advanced age. The nephrolithiasis, new growths and P.'s amyloidosis (see the Amyloidosis) meet at men more often, and P.'s polycystosis — at women. During the scheduling of inspection of the patient consider regional pathology (a nephrolithiasis, local a nephropathy, etc.).

Examining the patient, reveal hypostases of a renal origin which arise on a face more often and are combined with pallor of skin. At survey of a stomach and waist pay attention to a shape of a stomach and its sizes, participation of a stomach in the act of breath, existence of grazes, wounds, sites of pigmentation and reddening, scoliosis, patol, protrusion of soft tissues. The unilateral deforkhmation of a stomach in the form of a swelling in hypochondrium, more noticeable on a breath, meets at the new growths, cysts of a kidney, a hydronephrosis and other diseases which are followed by increase in the sizes P. Reddening and a swelling of a waist, especially in a combination to scoliosis towards defeat, a nek-eye bending of a leg in a knee joint and assignment in coxofemoral are characteristic of a paranephritis. The complicated urination and swelling in the bottom of a stomach over a pubis are observed at adenoma and a prostate cancer, urethrostenoses, a sclerosis of a neck of a bladder and other diseases, at to-rykh dynamics of urination is broken. Injuries of skin to area P. and uric ways with the expiration of urine to a wound indicate their getting wound.

The item is palpated two hands from a back and a front abdominal wall in position of the patient lying on spin, on one side, standing, sitting and, more rare, on a stomach, in genucubital situation (see. Palpation ). The items of the normal sizes located in the typical place are not palpated. If P. is palpated, then pay attention to its sizes, a form, a surface condition, sensitivity, degree of its mobility. By means of a palpation it is possible to distinguish patholologically mobile and dihundred-pyrobathing P., a new growth or a cyst, polycystic Items.

By means of easy effleurage of area P. reveal their morbidity serially on both sides. Slightly striking with finger-tips, an edge of a palm or a fist a brush of other hand in the area XII of an edge, in a kostovertebralny corner (see. Pasternatsky symptom ), reveal existence of pain and its character.

Auscultation in diagnosis of diseases of P. is used at recognition of pathology of renal arteries. At a renal artery stenosis systolic noise can be listened sideways from a backbone in lumbar area or in front in an anticardium. Rough and long noise is defined at zyachi-telny atheromatous damage and aneurism of a belly part of an aorta, existence of arteriovenous) the shunt of a kidney.

Much attention at P.'s diseases is paid to a research urine (see). Begin it with organoleptic assessment of svezhevyiu-shchenny urine (transparency, color, a smell, existence of inclusions). Then make a research of natural diuresis (see): define quantity of urinations per day, the volume and hourly distribution of the produced urine that gives an idea about fiziol, ekhmkost of a bladder; define relative density of urine in every portion, and also a diuresis per day, night and day. Close to a research of a natural diuresis there is a test across Zimnitsky (see. Zimnitsky test ). A research of a natural diuresis or by means of test across Zimnitsky receive data on total activity of the Item. Depending on a condition of an organism of P. normal remove the concentrated or divorced urine. If relative density of separate portions of urine within a day does not exceed 1,010 and osmolarity 285 mosm/l, then concoction of urine is considered insufficient (a symptom hypo - and isosthenurias). The night diuresis equal day or prevailing over it in the conditions of a normal drinking, feeding and temperature schedule, is observed at restriction of concentration ability of P. or a circulatory unefficiency. Decrease in concentration ability of P. is compensated quite often by increase in daily consumption of liquid and respectively increase in the daily amount of urine which is required for removal from P.'s organism apprx. 600 mosmol osmotically active agents and products of metabolism. If relative density of urine in separate portions exceeds 1,025 at a normal daily urine, then concentration ability of kidneys is considered undisturbed.

For bulk analysis it is better to use a morning portion of urine. When there is no an opportunity to investigate urine at once after an urination, it is kept on cold or add to it preservative (chloroform, toluene, a xylol, methyl-isopropyl phenol, formaldehyde, etc.). Bulk analysis of urine gives an idea of its physical properties, pH, protein content, the sugar and inclusions which are found in an uric deposit (leukocytes, erythrocytes, cylinders), existence of microbic flora. Changes of any of these indicators can indicate a disease of the Item. Quantitative definition of uniform elements in urine by means of Kakovsky's methods — Addis and Ambyurzhe (see. Kakovsky — Addis a method ) allows to estimate objectively morfol, structure of an uric deposit.

At inflammatory process carry out microscopy of an urocheras, coloring of smears from a deposit to P. methylene blue and across Gram, bacterial, and chemical determination of quantity of bacteria (see. Bacteriuria ).

Fluctuations of amount of hemoglobin, erythrocytes and the size of a color indicator of blood (see. Gemogramma ) are observed at malignant new growths of P., hron, a renal failure, acute malignant nephrite, a gemoliti-to-uraemic syndrome. The hyperleukocytosis, a deviation to the left, acceleration of ROE rather quickly develop at acute or an aggravation hron, inflammatory diseases of P., and also after operative measures on them and at malignant new growths

of P. Biokhim, a research, such as determination of content in blood serum of various products of exchange — residual nitrogen, creatinine, urea, uric to - you (see. residual nitrogen ), inorganic phosphate — are necessary in a complex research of secretory function P. From other biochemical blood analyses a certain significance is attached to identification of a hypoproteinemia, decrease albumine-globulinovogo of coefficient (see), hyperlipemias (see. Lipemia ), hypercholesterolemia (see) which are characteristic of a nephrotic syndrome.

The methodology of studying of excretory functions P. at their diseases consists in determination of two parameters, the first of to-rykh characterizes the mass of the operating nephrons (the operating parenchyma), and the second — separate processes of so-called canalicular transport.

At progressing P.'s defeats the mass of the operating nephrons (MON) naturally decreases, but, besides, the separate transport processes providing functions of body for regulation of constancy of internal environment of an organism are broken. Decrease in MDN involves reduction or loss of the majority of functions P., and only separate secretory functions a nek-swarm time are compensated by their adaptive strengthening in the remained nephrons. As a result disturbance of separate transport processes for a functional condition of P. appears parameter, naturally, clinically less significant, than MDN.

It must be kept in mind that all a wedge, quantitative methods of definition of renal functions give the chance to estimate the processes which are carried out by all parenchyma of body or all mass of the operating nephrons. Therefore the result of definition of each renal function reflects both MDN, and an average value of each function in the separate operating nephrons. The received size characterizes each of the studied functions only in case of safety of MDN. For assessment of damage of separate renal function previously determine size MDN. Quantitative assessment of both parameters of renal functions is necessary for establishment of a condition of separate excretory processes.

A recognized way of assessment of mass of the operating nephrons is secretion of Diodrastum or PAGE, and also the maximum reabsorption of glucose which are considered as the functions which are selectively not struck at P. Odnako's diseases their research is burdensome for the patient. With the same purpose use most often clearance of creatinine which is broken selectively only in an early stage of an acute glomerulonephritis or an acute phase of rejection of a renal transplant.

Separate canalicular functions study at simultaneous definition of MDN, napr, on the maximum canalicular secretion PAGE or to clearance of creatinine. It is accepted to use their relation to an indicator of MDN, a cut usually express as a percentage. E.g., measuring a renal plazmotok on clearance PAGE, estimate MDN on the maximum reabsorption of glucose and calculate the relation of absolute value of clearance PAGE to the absolute value of the maximum reabsorption of glucose, multiply the received private on 100. This indicator characterizes the speed of excretion PAGE realized by the mass of the operating nephrons, reabsorbiruyushchy 100 mg of glucose in 1 min.

At the decrease in clearance PAGE to 330 ml/min. which is followed by reduction of the maximum reabsorption of glucose to 160 mg! mines, the relation of their indicators makes 2,06, i.e. it is normal, and, therefore, secretion PAGE shall be recognized as normal. The same value of clearance PAGE at the maximum reabsorption of glucose of 320 mg! min. does the relation of these indicators equal 0,87 that allows to state the considerable decrease in secretion PAGE indicating reduction of speed of a renal plazmotok.

In process of progressing of renal defeats excretion of a number of metabolites with urine decreases and their concentration in a blood plasma increases. It belongs first of all to urea, creatinine, uric to - those, to hydrogen ions, sulfates, inorganic phosphates. Such disturbance of a homeostasis is estimated as an important stage in disturbance of the P.— functions renal failure (see). Respectively degree of a renal failure is characterized by the increased concentration of the mentioned substances in a blood plasma, hl. obr. creatinine and to a lesser extent — urea. Therefore as quantitative assessment of excretion of these substances at a renal failure first of all their level can serve in a blood plasma, but not clearance of creatinine or urea. But this circumstance does not exclude assessment of function of kidneys on clearance of these substances at all.

Intensity of excretion of P. of separate substances depends on the sizes of body which, in turn, directly correlate with the surface area and body weight. Therefore for the best comparability of the received results the indicator of renal functions is standardized for what the work of the received result at a size of a standard body surface (1,73 sq.m) is carried to a body surface of the examinee, to-ruyu determined by the nomogram, proceeding from growth and body weight.

Renal clearance — renal clarification — the most used indicator used for measurement of speed of renal excretion of a number of substances from blood. The term is offered in 1929 by Van-D. D. van Slyke and sotr. originally for assessment of intensity of excretion of urea. The renal clearance is calculated by a formula:

Renal clearance of substance = ([Concentration of substance in urine] / [Concentration of substance in a blood plasma]) * [A minute diuresis]

or

[Excretion of substance in 1 min.] / [Content of substance in 1 ml of a blood plasma]

the Maximum values (450 — 650 ml/min.) reaches renal clearance of the substances deleted by hl. obr. secretion of tubules of proximal departments of nephrons and only partially by glomerular filtering. Considerable sizes are reached by clearance of the substances deleted only by glomerular filtering and not reab-occluded by tubules. Minimum is a renal clarification of the substances which are exposed to filtering, but the most intensively reabsorbiruyemy tubules. The clearance of sodium making 1,8 +-0,8 ml \min. concerns to them. The renal clearance PAGE and Diodrastum, completely deleted from blood at its single course through P., is used for definition of rate of volume flow of a renal plazmotok; the clearance of inulin, Mannitolum and creatinine which are not exposed to a canalicular reabsorption and secretion, and also destruction in renal tubules and in uric system serves as an indicator of a glomerular filtration rate. Calculation of clearance is necessary for definition of canalicular secretion and a reabsorption of the substances which are exposed to glomerular filtering. Canalicular secretion is calculated as a difference between the speed of excretion of substance and the work of a glomerular filtration rate on the content of the corresponding substance in 1 ml of a blood plasma. The canalicular reabsorption of this or that substance (glucose, amino acids) is calculated as a difference between the work of a glomerular filtration rate on the content of this substance in 1 ml of a blood plasma and its minute excretion with urine. At the diffusion progressing renal defeats the renal clearance goes down to 2 — 5% of average normal value.

Measurement of renal clearance assumes definition of uric excretion of substance for strictly certain time term, during to-rogo concentration of this substance in blood is a constant or, at least, goes down according to the known pattern. Optimal conditions for determination of renal clearance are created at a research of excretion of endogenous metabolites, such, e.g., as creatinine and, in a smaller measure, urea, concentration to-rykh in a blood plasma during the research remains to a constant and for exact determination of clearance of special efforts it is not required. For exact definition of minute excretion it is necessary to receive all excreted urine that is reached by means of catheterization of a bladder (see. Catheterization of uric ways ) and subsequent its washing. This procedure can be replaced with a natural urination at rather high diuresis exceeding 1,5 ml/min.

A time term, during to-rogo collect urine, fluctuates depending on the applied technique of 20 — 30 min. to 24 hours; then average minute excretion of substance in milliliters in 1 min. is calculated. Big reliability of receiving all emitted substance is considered advantage of 24-hour clearance. However at such way issledovayeshya there is a possibility of a mistake because of individual daily fluctuations of function P., and also because of a hypouresis at night at the kept function of osmotic concoction of urine.

Measurement of a glomerular filtration rate. Minute intake of substances with a glomerular filtrate in the same concentration as in blood serum, and not exposed canalicular reabsorption, canalicular secretion, destruction and education in tubules and uric ways, shall equal their minute renal excretion. Therefore, the work of minute volume of a glomerular filtrate on the content of such substance in 1 ml of a blood plasma equals minute excretion. It means that the glomerular filtration rate is equal to renal clearance of these substances. Such properties are inherent fully in inulin and Mannitolum at, and also is approximate, at observance of the known conditions, to creatinine that allows to use their clearance for assessment of a glomerular filtration rate.

The determination of clearance of inulin made with high precision can be carried out along with definition of a renal plazmotok on clearance PAGE.

Determination of clearance of endogenous creatinine (Tareev's test — Reberg) — the most usable and applicable method of assessment of glomerular filtering. Inaccuracy of a method is connected with the fact that creatinine can be exposed to canalicular secretion owing to what the result of determination of clearance of creatinine exceeds a glomerular filtration rate. Secretion of creatinine is promoted by increase in its concentration in a blood plasma, and also considerable acceleration of a diuresis (to 4 ml/min. and above). On the other hand, at a research of clearance of creatinine against the background of the hypouresis which is not achieving 1 ml/min., the received result does not reach the true value. Considering these data, the condition of reliable use of clearance of creatinine for assessment of glomerular filtering should be considered carrying out a research in the conditions of the standardized moderate increase in a diuresis — from 1,5 to 2,5 ml/min. Normal value of a glomerular filtration rate — 90 — 130 ml/min. on 1,73 sq.m. Selective decrease in glomerular filtering is observed seldom.

The patient drinks on an empty stomach 500 — 750 ml of water or weak tea; in 45 — 60 min. urinates and to within 1 min. notes the moment of the termination of the act of an urination. For definition of excretion of creatinine collect two portions of the urine emitted for each of two following one by one of hour intervals. Strictly fix timepoint of the second and third urination. The time term for which the first studied portion of urine is collected equals to a time term between the second and first urination; a time term, during to-rogo the second portion of urine is allocated, equals to an interval between the third and second urination. The blood sample for definition of creatinine is taken in one of these intervals. For the analysis can be used both plasma, and blood serum.

Permeability for protein — the important function depending on passability of the glomerular filter, ability to a reabsorption of serum proteins reflects defeat of renal balls. Practical value has detection of permeability for albumine about a pier. it is powerful (weighing) 60 000 and above. An indicator of permeability of kidneys for serum protein is patol, the proteinuria with daily excretion of protein of St. 100 — 150 mg.

A certain significance is attached to so-called selectivity of a proteinuria, under a cut understand sharp dominance of excretion of middlemolecular proteins (transferrin, albumine) over excretion of high-molecular proteins — immunoglobulins G and M, alfa2-macroglobulin. Quantitatively selectivity of a proteinuria is estimated, determining an index of selectivity by Cameron — Bledfordu: attitude of clearance of IgG towards clearance of serumal transferrin or seralbumin. The proteinuria is considered the selection if the index does not exceed 30%, and non-selective in case of detection of higher values. Not selectivity of a proteinuria means the increased penetration into a glomerular filtrate of high-molecular proteins and is considered as manifestation of more severe defeat of structure of renal balls.

Definition of concentration of separate serum proteins assumes two stages, one of to-rykh consists in establishment of absolute concentration of protein in blood serum or urine, and the second — in direct establishment of fractional content of separate serum proteins. Definition of serum protein in both substrates is possible by means of refractometry (see), it is especially reliable at use of biuret reaction (see) or Lauri's method (see Lauri a method). Establishment of fractional contents is reached by an electrophoresis on gels — starched, acrylic (see the Electrophoresis), and also immunodiffusion according to Mancini (see. Immunodiffusion ) or an immunoelectrophoresis (see).

Measurement of a renal plazmotok. Clearance of substances, completely or almost completely deleted at course of blood through P., tozhdestven rate of volume flow of an effective renal plazmotok. The renal clearance means the volume of a blood plasma which is exempted from the studied substance in 1 min. Clarification from these substances is carried out by an overwhelming part of a renal parenchyma (apprx. (90%). Therefore the renal clearance of the substances which are completely excreted from a blood plasma at its passing through the functioning part P. carries the name of the effective renal plazmotok unlike the general expected all renal parenchyma. Determination of speed of the general renal plazmotok assumes receiving blood from a renal vein, and she can be found as follows:

An effective renal plazmotok = [a minute ekskrektion of test substances] / (A-in),

where And — concentration of test substances in arterial, and In — in a venous blood.

The formula is based that the difference between the mass of the test substance which came with an arterial blood to P. and left it in 1 min., shall equal to the amount of this substance which is marked out during this time with urine. An effective and general renal plazmotok are expressed in ml! mines are also presented in the form of value, they would correspond to Krom at a body surface of the patient, equal 1,73 sq.m. For calculation of an effective and general renal blood-groove the result of definition of a plazmotok is divided into a difference between 100 and the indicator of a hematocrit expressed as a percentage and private multiplied on 100.

Carry Diodrastum to number of the substances applied to definition of a renal plazmotok, so-called test substances, gippuran, PAGE. During the use of chemical methods of definition of concentration of test substances in urine and a blood plasma preference is given PAGE, during the use of radionuclide methods — to a gippuran. The normal clearance PAGE makes 500 — 700 ml/min., and an effective renal blood stream — from 833 to 1170 ml! min. The general renal plazmotok equals 680 — 800 ml/min., and the general renal blood stream — 1130 — 1330 ml/min.

Selective decrease in an effective renal plazmotok is observed at arterial hypertension, and also at heart and acute vascular failure. The known significance is attached to so-called filtrational fraction, the relation of a glomerular filtration rate to the speed of an effective io-chechny plazmotok; the result is expressed as a percentage. Normal value of filtrational fraction averages 20%. Increase in filtrational fraction is peculiar to arterial hypertension, decrease — to an acute glomerulonephritis or an aggravation hron, a glomerulonephritis.

The combined determination of clearance of inulin and a paraaminogippurat (PAGE). In 30 min. prior to the research of the patient drinks 500 ml of weak tea. Then enter a catheter into a bladder. From an intermediate vein of an elbow (v. intermedia cubiti) gain 10 ml of blood in a test tube with heparin. Then start injection of an initial dose of both substances to create concentration, necessary for a research, in blood serum. Within 5 min. enter 30 ml of 10% of solution of inulin and 2 ml of 20% of solution PAGE. Further maintain the reached concentration of both test substances by means of the solution consisting of 8 ml of 20% of solution PAGE and 70 ml of 10% of solution of inulin in 500 ml of 0,85% of solution of sodium chloride which is entered into a vein with a speed of 3 — 4 ml! min. In 30 min. after the beginning of injection of a maintenance dose urine is produced, the bladder is washed out warm isotonic solution of sodium chloride, block a catheter and note time. Then within 3 periods lasting 20 min. investigate clearance of both substances (or one of them). At the end of each time slice remove a clip from a catheter and by washing of a bladder collect the studied substances excreted with a kidney with urine. The moment of crossclamping of a catheter after each washing of a bladder is fixed. During each of these 3 periods through equal intervals gather blood from other vein for definition of test substances in it.

Uric excretion is calculated as performing maintenance of substance in 1 ml of contents of a bladder on all volume of the received liquid (including and rinsing waters), divided into time, during to-rogo urine for a research gathered. For calculation of clearance use concentration of substance in the plasma extracted in the second period of a research or an arithmetic average from concentration in each of three tests of plasma.

The Fenolsulfonftaleinovy test (fenolrotovy test) is carried out for the purpose of establishment of speed of removal of a fenolsulfon-ftalein of P. which is removed preferential by secretion in proximal department of tubules and only partially by glomerular filtering. Results of test reflect a renal plazmotok, and it can be considered as a semi-quantitative method of assessment of this function.

Because the renal blood stream is selectively broken at arterial hypertension, heart and acute vascular failure, results of test can reflect safety of the mass of the operating nephrons (MON). At the mentioned morbid conditions for assessment of a functional condition of P. define the clearance of creatinine which is the simplest method of measurement of MDN. Apply the following modification of the test. Test is carried out on an empty stomach. For the purpose of maintenance of a sufficient diuresis necessary for obtaining exact result, the patient drinks 500 — 600 ml of water, then in 1 hour intravenously enter 6 mg phenol a company and in 15 min. collect a portion of urine, in a cut establish amount of the emitted paint. Sometimes excretion of phenol red is investigated in time terms up to 15 min., from 15 to 30 min., from 30 to 60 min., from 60 to 120 min. after its introduction. However only determination of amount of the drug emitted in the first 15 min. after injection since 2-hour excretion of phenol red can be normal even at sharp restriction of MDN is of value. Normal in the first 15 min. from 28 to 51%, on average 35%, i.e. from 1,7 to 3 mg, on average 2,1 mg of the entered amount of phenol red are allocated. Advantages of this test are not complication for the patient, and also simplicity of chemical definition, a cut assumes alkalifying and colorimetry of divorced urine.

The by-effects connected with administration of phenol red no.

Research of ability of kidneys to osmotic concoction and osmotic cultivation of urine. The principle of definition of concentration ability of P. consists in establishment of ability to formation of urine of rather high osmotic concentration or specific weight in the conditions of dehydration having a promoting effect on natural products of antidiuretic hormone. Ability to osmotic cultivation of urine is established urine of low osmotic concentration by training in the conditions of the excess hydration blocking secretion of vasopressin. Renal regulation of an osmotic homeostasis is carried out fully only if MDN is kept or only slightly lowered. There is a natural communication between clearance of creatinine and ability to osmotic to optsentr and a ditch of An iyu, in yr and zha a yushcha of a yasa that decrease in MDN is followed as well by decrease in osmotic concoction of urine. However at the progressing nefropatiya, and in particular at a glomerulonephritis and pyelonephritis, disturbance of this function can precede decrease in clearance of creatinine. Such ratios between both functions indicate an interstitium of the Item a possibility of selective disturbance of the osmotic concoction of urine inherent to a sclerosis.

Osmotic concoction of urine but to comparison with osmotic cultivation of urine suffers earlier and more considerably at the progressing renal defeats owing to what the research of the first of these functions is given preference. It is reasonable to determine both functions by regulation of an osmotic homeostasis in the conditions of the maximum stimulation. Osmotic concentration of urine reaches 90% of the maximum value at 18-hour dehydration and it is limit at dehydration St. 26th hour.

In the conditions of the maximum dehydration osmotic concentration of urine shall be higher than 900 mosm/l, reaching 1200 — 1300 mosm/l, and its specific weight — not lower than 1,025, reaching 1,028 — 1,030.

Definition of ability, less burdensome for the patient, to osmotic concoction of urine can be carried out by restriction of liquid during 12 hours and the subsequent introduction of 5 PIECES of oil solution of vasopressin. In these conditions osmotic concentration of urine reaches 800 — 900 mosm/l.

Test on ability to osmotic cultivation of urine assumes the water loading (20 — 22 ml! kg of body weight) which is carried out on an empty stomach within 30 — 40 min. The patient drinks water or weak tea. After that during the closest 2 hours collect urine every 30 min., only four portions. After each urination it is necessary to fill a fluid loss with urine for what drink a necessary amount of water. The maximum ability to cultivation at this test is defined by the minimum level of osmotic concentration of urine or specific weight. The normal indicator of osmotic concentration of urine in the conditions of water loading makes 30 — 80 mosm/l; specific weight of urine goes down to 1,001.

Test across Zimnitsky allows to estimate approximately P.'s ability to regulation of an osmotic homeostasis. Against the background of a usual diet and daily consumption of liquid of 1 l (at stay in conditions of air temperature from 20 to 26 °) each 3 hours within a day collect urine and measure the volume and specific weight every portion. Daily fluctuations ud. the weight of urine shall make from 1,005 to 1,022. The maximum specific weight not higher than 1,018 forces to suspect disturbance of concentration ability; specification of it requires the test with dehydration allowing to reveal disturbance of ability of a kidney to regulation of an osmotic homeostasis — isosthenuria (see). At the same time the specific weight of urine fluctuates ranging from 1,008 to 1,015.

Other methods of a research

value of a tool research Is big: tsistoskopiya (see), hromotsistoskopiya (see), catheterizations of ureters with separate receiving from P. of urine for a research. Tool researches are not indifferent for the patient therefore they are carried out according to strict indications.

Are obligatory rentgenol. methods, among to-rykh are widely used a survey X-ray analysis, P.'s tomography (see. Tomography ), a computer tomography (see. Tomography computer ), excretory urography (see), the ascending and descending piyeloureterografiya (see. Piyelografiya ), renal angiography (see), kavografiya (see), the location and the sizes of kidneys, their form, structure of uric ways, a functional state allowing to define on release of radiopaque substances, a very techtonic dance of vessels of a kidney, existence in a kidney of stones, splinters, and also will reveal

P. V damages a complex research P. the important place the radio isotope research, provodrdoy for the purpose of studying of their function, assessment of a condition of a renal blood-groove and obtaining the image of body takes. The possibility of a separate research of function of each P., relative simplicity and high informational content provided broad use of such methods as a radio isotope renografiya (see. Renografiya radio isotope ), scanning of kidneys (see. Scanning ), stsintigrafiya (see), ultrasonic diagnosis (see) and termografiya (see). Definition of function P. and passability of upper uric ways is carried out by means of a radio isotope renografiya (see. Renografiya radio isotope ). The condition of canalicular secretion is studied using gippurana- 131 I, and glomerular filterings — by means of EDTA- 51 Cr or DTPA- 99m Tc. Renografiya by means of DTPA and EDTA can reveal disturbances of glomerular filtering at preservation of concentration ability of a kidney.

Stsintigramma of the patient with the only left kidney with the phenomena of a renal failure, received on the SEGAMS COMPUTER by method of a dynamic renostsintigrafiya with radioactive technetium (99mTc — DTPA). Fig. 1. Stsintigramma received in 2 — 3 min. after administration of radioactive drug: against the background of the surrounding fabrics containing a large amount of radionuclide the image of a left kidney is indistinctly selected; the image of a right kidney is absent. Fig. 2. Stsintigramma received in 5 — 6 min. after administration of radioactive drug: the clear image of the left kidney which is usually located and a little increased in sizes with equal contours; the image of a right kidney is absent; on the right there is an image with indistinct contours caused by accumulation of radionuclide in a liver (a symptom of a renal failure). Fig. 3. Stsintigramma received in 10 — 12 min. after administration of radioactive drug: a little the sizes of the image of a left kidney decreased and there was an image of a left ureter as a result of a delay of radionuclide in it (it is characteristic of an atony of an ureter). Fig. 4. Stsintigramma received in 15 min. after administration of radioactive drug: decrease of the activity of a left kidney owing to excretion of urine; activity of a liver continues to remain. Fig. 5. Stsintigramma received in 20 min. after administration of radioactive drug: the image of a left kidney and ureter remains rather clearly, also the image of a liver remains. Fig. of century. Computer processing of results of a research with creation of the schedule «activity — time»: above — the zones which are of interest limited to white lines and allocated with color rectangles including areas of the left and absent right kidney, a liver (a green rectangle), and also separately a pelvis of a left kidney (a rectangle in a left kidney); below — the curves received on the basis of these data (a curve of red color — the renogramma characterizing secretory and excretory functions of a left kidney; a violet curve — the pelvigramma characterizing accumulation and removal of radionuclide from a pelvis of a left kidney; the green curve reflects dynamics of release from radionuclide of a liver and the fabrics surrounding it; the yellow line — a background curve from a zone of the absent kidney). On graphics on a vertical axis activity of radionuclide, on a horizontal axis — time in minutes is shown. On slides: the vertical color scale shows degree of intensity of accumulation of radionuclide in bodies and fabrics.

Studying of a form, the sizes P. and the nature of distribution of drug is carried out with the help scannings (see) and stsintigrafiya (see). Scanning is carried out in 1 hour after intravenous administration of radio pharmaceutical drug. Normal on P.'s skanogramma — an oval or fabiform form with hypodispersion of drug. At hron, inflammatory processes picture contrast decreases, distribution of drug becomes uneven. Tumors, P.'s cysts are characterized by change of a form, the size and existence of defect of accumulation. Stsintigrafiya P. in dynamics allows to study, in addition to obtaining their image, sekretornoekskretorny process in kidneys, to estimate function of all parenchyma and its separate segments. Stsintigrafiya is carried out on the gamma camera directly after intravenous administration gippurana- 131 I or DTPA- 99m Tc. Results of a research are processed by means of the computer according to special programs (tsvetn. fig. 1 — 6). Normal on stsintigramma in the range of 0 — 5 min. gradual increase of activity is noted. On 2 — the 4th min. comes to light the maximum accumulation and the most sharp image of P., zatekhm removal of drug begins, and P.'s image disappears. Signs of dysfunction of P. are delay of accumulation and removal of drug from P. or its separate segments. For diagnosis of the hypertensia connected with defeat of vessels of kidneys, napr at atherosclerosis, thrombosis of renal arteries, apply a scintiangiography (see) also determine the speed of passing of drug through kidneys. The research is conducted after intravenous administration 113gp1p or 99tts. Normal radionuclide comes to an aorta in the beginning, then to renal arteries and vessels of a renal parenchyma. At a stenosis of renal arteries delay of speed of a blood-groove is noted, the speed of removal is also slowed down. Intensive accumulation of drug in a zone of defeat on angiostsintigramma is characteristic of tumors of kidneys and defect of accumulation on P.'s stsintigramma

the Biopsy of a kidney

the Important place in a research P. belongs biopsies (see), edges it can be executed by a transdermal puncture, in the half-open way or on bared by P. Biopsiya on open P. has some advantages since at the same time it is possible to take fabric from suspicious site P., practically avoiding complications. The biopsy of a kidney is applied in cases when other methods of a research do not allow to establish the diagnosis. By means of histologic, histochemical, immunofluorescent, electronic microscopic examination of fabric P. it is supposed to specify the diagnosis and to appoint rational therapy, to track course of disease in the course of treatment. P.'s biopsy is applied most often at diagnosis hron, a glomerulonephritis, an amyloidosis, various nefropatiya, at a proteinuria and a renal hamaturia of not clear etiology. It is contraindicated in a terminal phase of renal and heart failure, at the expressed anemia, disturbance of coagulability of blood, a paranephritis, a pyonephrosis, a hydronephrosis, aneurism of a renal artery, anomalies of renal vessels, at fibrinferment of renal veins, new growths, an actinomycosis and P.'s tuberculosis, and also at inoperable patients. The question of a biopsy of the only functioning or transplantirovanny P. is solved individually.

P.'s biopsy is carried out in the conditions of a hospital under local anesthesia, at children — under anesthetic. Before a biopsy by means of radio isotope, rentgenol. methods, and sometimes and an angiography, define situation, a form and the sizes P. The patient at a transdermal and half-open puncture biopsy is in a ventral decubitus on the firm roller, and at an open biopsy — in the edgewise position used for a lumbotomy and operations on P. Legche to punktirovat the left P. that should be meant at diffusion bilateral defeats. At a puncture and half-open biopsy pieces of fabric P. take from the lower pole at distance 2 — 3 cm from its lateral edge.

Needles like Silvermen in various modifications are applied to a biopsy by a transdermal puncture. The tissue extractor is entered into fabric P. on depth of 1,5 cm. The movement of a needle corresponding to respiratory excursions points that it is in renal fabric. After a biopsy to the place of a prick apply a compressing bandage and the patient stack on 30 — 50 min. lumbar area on the dense roller. During the day the patient shall observe a bed rest, and in the presence of complications — before their disappearance. The repeated biopsy is possible not earlier, than in 5 — 7 days.

The most frequent complications of a transdermal biopsy of P. are: micro and gross hematuria, pain, fervescence, Pararenal hematoma or urohematoma; are extremely seldom observed peritonitis (see) and anury (see).

PATHOLOGICAL ANATOMY

Fig. 8. The diffraction pattern of a kidney at hyaline and drop dystrophy of an epithelium of renal tubules: in cytoplasm of a nephrocyte numerous hyaline educations (1) and vacuoles (2) are visible, destruction of mitochondrions is noted (3); X 18 000.
Fig. 9. Microdrug of a kidney at a system lupus erythematosus: shooters specified the centers of a fibrinoid necrosis of capillaries of a renal ball; coloring hematoxylin-eosine; X 400.

At morfol, a research in P. dystrophic, necrotic, inflammatory changes, disturbances of blood circulation, etc. can be found. In P. proteinaceous, fatty, carbohydrate, mineral dystrophies can be observed. At proteinaceous dystrophies (see) in one cases preferential renal tubules (parenchymatous Disproteinoza), in others — renal balls, a stroma, vessels are surprised (mesenchymal Disproteinoza). Granular, gialinovokapelny and gidropichesky dystrophies occur among parenchymatous disproteinoz in P. If granular dystrophy reflects strengthening of reabsorbtsionny function of nephrocytes, then gialinovokapelny and gidropichesky dystrophy — insufficiency of this function of hl. obr. concerning protein and water that is characteristic first of all for nephrotic syndrome (see), nek-ry types of hereditary canalicular enzymopathies. Therefore at hyaline and drop and gidropichesky dystrophy, in addition to accumulation of proteinaceous gialinopodobny drops and water in cytoplasm of nephrocytes, destruction of mitochondrions, cytoplasmic reticulum, brush border (fig. 8) is observed. The heaviest is so-called balloon dystrophy of an epithelium of tubules (a focal kollikvatsionny necrosis). Mesenchymal Disproteinoza P. are presented by fibrinoid swelling (see. Fibrinoid transformation ), hyalinosis (see) and amyloidosis (see). The fibrinoid swelling of glomerular circulatory capillaries, walls of arterioles and arteries of kidneys which is coming to the end with quite often fibrinoid necrosis (fig. 9) reflects morphologically reaction of hypersensitivity and comes to an end glomerulo-and arteriologiali-nozy. P.'s amyloidosis meets usually at secondary and hereditary forms of the general amyloidosis; at primary amyloidosis it is rare. Adjournment of amyloid in renal balls, vessels, a stroma is, as a rule, combined with proteinaceous and fatty dystrophy of an epithelium of renal tubules. Refer changes at paraproteinemias and disturbances of exchange of nucleoproteids to special types of proteinaceous dystrophy of P. Changes are considered as hron, obstructive tubulopatiya also are most expressed at a multiple myeloma and gout. At a multiple myeloma in connection with «contamination» of a stroma of P. and obstruction of renal tubules low-molecular protein a paraprotein the paraproteinemic nephrosis, or a myeloma kidney develops (see. Multiple myeloma ). At gout in connection with the increased content in blood and urine of salts uric to - you they are postponed in P.'s stroma, renal tubules and collective renal tubules, causing their obstruction, inflammatory and atrophic changes called by a gouty kidney (see. Gout ). Also education in the Item is connected with disturbance of exchange of nucleoproteids at newborns. urate heart attack (see).

At fatty dystrophy of P. (see. Fatty dystrophy ) lipids (neutral fat, cholesterol and its ester, phospholipids) collect in nephrocytes of tubules of proximal and distal departments of nephron, and also in P. V stroma nefro-shchgga of a drop of lipids push aside organellas, at the same time signs of their destruction are expressed poorly. In a stroma there are foamy cells — macrophages, rezorbiruyushchy lipids. The most often fatty dystrophy of nephrocytes and stroma of II. meets at a nephrotic syndrome and hron, a renal failure, is more rare at the general obesity, a diabetes mellitus, action of microbic agents, and also phosphorus, perchloromethane, an aflatoxin of Century. Chances of local adjournment of neutral fat and cholesterol in intersticial fabric and in own membrane of tubules. Such, a wedge-shaped form, well limited sites of white-yellow color are located quite often in a renal nipple («a fatty heart attack» of a kidney).

Accumulation of lipids in P. has usually resorptive mechanism and reflects as deficit of enzymes of the nephrocytes metabolizing fat, and resorptive insufficiency of macrophages of a stroma and limf, systems P. The exception is made by fatty dystrophy of mezangialny cells of renal balls, edges is a pathognomonic sign of a focal segmented glomerular hyalinosis (see. Glomerulonephritis ) also confirms probably a hereditary fermentopatiya.

Carbohydrate (glycogenous) dystrophy of P., or a so-called glycogenous nephrosis in the form of adjournment of a glycogen in nephrocytes of renal tubules, especially narrow segment of a loop and distal department of nephron, and also in P.'s stroma meets at a diabetes mellitus (see. diabetes mellitus ) a glycogenosis to Awnless wheat (see. Glycogenoses ). At a diabetes mellitus adjournment of a glycogen reflects processes of synthesis of a glycogen at a resorption of an ultrafiltrate of plasma rich with glucose in nephrocytes; nephrocytes become high, with light foamy cytoplasm, grains of a glycogen are visible also in a gleam of tubules. At a glycogenosis to Awnless wheat accumulation of a glycogen in P., as well as in a liver, is connected with hereditary deficit of glikozo-6-phosphatase, metaboliziruyukhtsy a glycogen.

In P. dystrophic changes at disturbances of exchange of endogenous pigments often are found. At acute hemolysis, excess accumulation in blood and urine of soluble hemoglobin, hematin and ferritin the so-called hemolitic kidney, or a gemoglobinurm-ny nephrosis develops; at hron, the hemolysis conducting to a widespread hemosiderosis in nephrocytes and P.'s stroma hemosiderin (a hemosiderosis of kidneys) is laid. At jaundice of any genesis in connection with P.'s allocation bilious to - t and their salts there are heavy dystrophic and necrobiotic changes of renal tubules that is the cornerstone of an icteric nephrosis.

Mineral dystrophies in P. arise in connection with disturbances of exchange of calcium and phosphorus (see. Mineral dystrophy). They are characterized by loss of salts of calcium in nephrocytes at metastatic and metabolic calcification (see the Nephrocalcinosis), the formation of urinary stones (see) which is the cornerstone nephrolithiasis (see).

The epithelium of tubules of various sites of renal fabric can selectively be exposed to a necrosis. The necrotic nephrosis, or a nekro-nephrosis, meets at an acute renal failure. Necrotic changes of an epithelium have focal character and are followed by destruction of basal membranes preferential of tubules of distal department of nephron (tubulorrhexis). The cylinders which are formed in a gleam of renal tubules at the different levels block nephrons that conducts to accruing a nave-rogidrozu, to hypostasis of intersticial fabric; the venous plethora, leukocytic infiltration, hemorrhages, thrombosis of vessels are noted. Items at the same time are increased in sizes, bulked up, edematous, with the intense fibrous capsule; wide white-gray cortical substance is sharply delimited from dark red renal pyramids, in yukstamedullyar-ache to a zone and in a pelvis hemorrhages are quite often visible.

Fig. 10. Macrodrug of a kidney at a symmetric cortical necrosis (a frontal section): shooters specified the centers of a symmetric cortical necrosis of a kidney.

Special type of a necrosis of P. is the symmetric cortical segmented or total necrosis (fig. 10). In its emergence the main role is played long ischemia of P. owing to circulator disturbances; also the role of allergic mechanisms is not excluded.

Disturbances of blood circulation and a lymphokinesis in P. can be expressed by an arterial and venous plethora, a lymphostasis and hypostasis, an anemia, a heart attack, hemorrhages.

The arterial plethora (hyperemia) of P. is observed as at the general disturbance of blood circulation, napr, at increase in volume of the circulating blood (see. Plethora ) or quantities of erythrocytes (see. Hyperglobulias ), and during the strengthening of function of P. (functional congestion). Items at an arterial plethora increase in sizes, become bright red; arteries and their veins are full-blooded, in an epithelium of tubules of proximal departments granular dystrophy is noted. The venous plethora (hyperemia) of P. can be manifestation of the general venous plethora at acute or hron, cardiovascular insufficiency or is connected with disturbance of outflow of a venous blood at fibrinferment or a prelum of veins of the Item. The venous plethora conducts to a sharp trichangiectasia and venules, to a lymphostasis, intersticial hypostasis and increase in intra renal pressure that promotes increase of a hypoxia of renal fabric. Development of dystrophic changes of an epithelium of tubules proximal, departments and a sclerosis of brain, and then cortical substance is connected in the beginning with a hypoxia. At long venous stagnation there is a Tsianotichesky induration of P., however wrinkling is observed seldom. Items become big, dense, cyanochroic. Veins of marrow and yukstamedullyarny zone are especially full-blooded; renal nipples put in small renal cups that can lead to infringement of fornikalny veniplexes and a hamaturia.

P.'s anemia can be display of anemia or insufficient blood supply as a result of a hypoplasia, atherosclerosis, arteritis, thrombosis, a prelum of a renal artery. The item looks pale, serozhelty color on a section; dystrophy of an epithelium of renal tubules is combined quite often with its regeneration. Long obturatsionny ischemia of P. conducts to its atrophy and to a nephrosclerosis (see).

P.'s heart attacks can be arterial, or ischemic, and venous, or hemorrhagic. Arterial heart attacks are usually connected with a thromboembolism, is more rare with thrombosis of renal arteries and develop usually against the background of cardiovascular insufficiency at heart diseases and vessels. Seldom traumatic heart attacks of P. meet, in development to-rykh a big role plays a spasm of arteries. Connect with a spasm of arteries also development of heart attacks in an opposite kidney at wound of the Item. Arterial heart attacks of P., according to V. V. Serov, in 69% happen bilateral, in 12,2% — repeated and in 88% are combined with heart attacks of other bodies. The arterial heart attack, as a rule, white color with a hemorrhagic nimbus, a cone-shaped form taking cortical substance or all thickness of a parenchyma; the nuclear-free field of a necrosis is delimited by a zone of a hyperemia and leukocytic infiltration. In some cases during the closing of the main arterial trunk the total or subtotal heart attack of the Item develops. Venous heart attacks of P., according to S. Koberiiick, J. Moore, At a needle at F. Wiglesworth, make no more than 2% of all heart attacks of P. Voznikayut they in connection with stazy in system of renal veins or their thrombosis, is more often at P.'s amyloidosis or at toxicosis and an eksikoza at children at diseases went. - kish. path. After a congestive hyperemia, stazy and hemorrhages there is a necrosis of a parenchyma of P., secondary thrombosis of renal arteries and the related ischemic heart attacks of cortical substance develop. The kidney at a venous heart attack looks motley: on a dark red background of a renal parenchyma with sites of hemorrhages gray-red wedge-shaped fields in cortical substance are found. The most frequent outcome of a heart attack of P. — scarring that leads in some cases to macrofocal postinfarction nephrosclerosis; purulent fusion of a heart attack as it happens is less often observed, e.g. at a septicopyemia (a septic heart attack of P.).

Hemorrhages in P.'s parenchyma usually diapedetic and multiple, meet as display of hemorrhagic diathesis, generalized infection (sepsis, plague, a malignant anthrax), intoxications, shock. They are characteristic also of a number of diseases of P., napr, a subacute glomerulonephritis, a hemorrhagic nephrosonephritis, at Krom of hemorrhage arise usually in marrow and a pelvis of the Item. Hemorrhages meet a spontaneous gap also in transplantirovanny P.

Vospaleniye P. is morfol, a basis of many nefrol, and the Urals, diseases. The acute inflammation to them-munokompleksnogo genesis with participation of bacterial (streptococcus) antigens and preferential localization of process in renal balls is the cornerstone of acute glomerulonephritis (see). Hron, the inflammation of renal balls caused by the circulating cell-bound immune complexes with unspecified antigen makes essence hron, a glomerulonephritis.

The acute intersticial serous or purulent inflammation of P. is characteristic of acute pyelonephritis (see). At the same time small or large abscesses are formed, at merge to-rykh there is an anthrax of the Item. It has an appearance of a tumorous node of the yellow or crimson-blue color taking cortical and marrow. The fibrous capsule, adjacent to an anthrax, is thickened also a belesovata at the expense of the ripening granulyatsionny and fibrous fabric. Progressing of an inflammation conducts to the message of purulent cavities of an anthrax with a pelvis — to a pyonephrosis (see), to transition of process to the fibrous capsule — to a perinephritis (see) and pararenal cellulose — to a paranephritis (see); quite often process is complicated by a necrosis of renal nipples (see. Renal nipples necrosis ). Multiple abscesses in P. can arise at hematogenous distribution of contagiums; in these cases develops embolic purulent or apostematous nephrite (see). The item at the same time it is covered with small flavovirent pustules with a red nimbus of a hyperemia on the periphery; in sites of purulent fusion of fabric bacterial clumps are found.

Hron, an intersticial inflammation with growth of connecting fabric, encapsulation of abscesses, a macrophagic resorption of necrotic masses, polipozy and a metaplasia of a mucous membrane of a pelvis and cups is the cornerstone hron, pyelonephritis. In its final the pyelonephritic wrinkled P. develops (see. Nephrosclerosis ), for a cut uneven cicatricial wrinkling, a dense spayaniye of fabric P. with the fibrous capsule, a sclerosis of a pelvis and peripelvic cellulose is characteristic.

Specific hron, P.'s inflammation is observed at tuberculosis and syphilis.

P.'s tuberculosis results from hematogenous distribution of causative agents of tuberculosis. Distinguish focal and destructive its forms which can have acute or hron, a current. In the beginning the gray-yellow centers of a caseous necrosis arise in cortical, then marrow P. (an acute focal form). At dominance of productive fabric reaction a number of the centers is encapsulated and petrifitsirutsya (hron, a focal form). However the caseous necrosis of renal nipples develops much more often, cavities (an acute destructive form) are formed. Obturation of an ureter caseous masses leads to development of a tubercular pyonephrosis. During the progressing of process it can pass to a pelvis, an ureter where grumous rashes develop, and then ulcers and hems are formed. At hron, a current of a destructive form of tuberculosis sclerous processes, encystment and calcification of sites of a caseous necrosis develop in P. At dominance of a sclerosis and petrification P.'s wrinkling develops, at a total porazhenrsh of body — wrinkled calciphied, or omelotvorenny, P.

Krayne cases hron, P.'s tuberculosis seldom meet a diffusion intersticial inflammation, a cut quickly evolves in a nephrosclerosis; in intersticial fabric P. in such cases epithelial and lymphoid cells prevail, find a large number of mycobacteria of tuberculosis. This kind of tuberculosis of P. is called tubercular intersticial nephrite or a kokhovsky nefrotsir-roz. Special form of tuberculosis of P. is tuberculoma (see), edges it is sometimes encapsulated and obyzvestvlyatsya. As display of hematogenous generalized tuberculosis in P. can arise acute miliary tuberculosis. See also Tuberculosis extra pulmonary, tuberculosis of urinogenital bodies.

P.'s syphilis is observed, according to various researchers, in 0,48 — 0,7% of cases of visceral syphilis. At primary syphilis of change of P. characterize as the high-quality vascular disease which is followed only by a periodic albuminuria and a microhematuria. In P.'s stroma in such cases find infiltrates from plasmocytes, in an epithelium of tubules of proximal (main) departments of nephrons — granular dystrophy. At secondary and tertiary syphilis the lipoid nephrosis and syphilitic intersticial (fibrous) nephrite are observed. At the last P. are increased, cortical and marrow are badly distinguishable on a section, the cut surface has light-brownish color. Considerable hypostasis of intersticial fabric P., focal or diffusion infiltration its lymphoid, by plasmocytes, macrophages, fibroblasts, deposits of cholesterol are noted. In intersticial fabric find a pale treponema. An outcome of syphilitic nephrite is a nephrosclerosis (nefrotsirroz). At tertiary syphilis find the gummas having an appearance of the white-yellow large nodes which are located both in cortical and in marrow, and sometimes and in a pelvis of a kidney in P. The result of gummous defeat — scarring with rough deformation of P., sometimes with a secondary amyloidosis.

Miliary gummas in the form of small ocherous small knots, evenly scattered in fabric P are characteristic of inborn syphilis. Carry also intersticial nephrite of newborns to inborn syphilis, for to-rogo, in addition to specific infiltration of intersticial fabric, existence in tubules of large cells with a big kernel and wide light, a rim of cytoplasm is typical. In P.'s stroma find a pale treponema in such cases. See also Syphilis.

Peculiar hron, the purulent inflammation of P. is observed at an actinomycosis which usually is secondary. In P. there are dense, yellow color nodes, single, also marrow is more rare multiple, fascinating cortical. The fabric surrounding them is condensed and contains the sotovidny, filled with purulent exudate sites which are sometimes reported with perinephric cellulose. In exudate druses an actinomyce can be found. P.'s parenchyma of an infiltrirovan granulyatsionny fabric, specific to an actinomycosis, from epithelial, lymphoid, plasmatic and ksantomny cells. The centers of purulent fusion are surrounded with the ripening granulomas and the cicatricial fabric containing crystals of cholesterol. See also Actinomycosis .

Mycotic defeat of P. is possible also at candidiasis. It arises hematogenous and ascending in the ways. In cortical substance at the same time there are small abscesses, the centers of a necrosis and granuloma extending then on a pelvis and an ureter. See also Candidiasis .

Many inflammatory diseases of P. are connected with an invasion of protozoa and helminths. Development of an immunocomplex acute glomerulonephritis is connected with effect of antigen of a malarial plasmodium. Among parasites in development of an inflammation of the echinococcus, a shistosoma and filarias have the greatest value. At gidatidny echinococcosis (see) one P. is surprised usually, is more often left, in cortical substance a cut two bubbles appear one, more rare. The wall of a bubble represents the dense fibrous capsule covered by a chitinous cover. From an inner germinative layer of this cover there are affiliated bubbles with a scolex. They fill a cavity of a maternal bubble which increases, reaching time of the huge sizes. P.'s parenchyma surrounding an echinococcal bubble is exposed to an atrophy. Sometimes contents of a bubble break in renal cups and a pelvis; its infection is possible. The died parasite is exposed to petrification. At alveococcosis (see) P. are surprised gematogenno with development of quite often multiple centers. Oncospheres give rise to development at once of several bubbles which grow by budding, infiltriruya surrounding fabric and causing its necrosis. Around focuses of a necrosis granulyatsionny fabric expands, in a cut there are a lot of eosinophils and colossal cells englobing covers of the perishing bubbles. At P.'s alveococcosis, as well as a gidatidny echinococcosis, suppuration of bubbles and calcification at their death is possible.

At a schistosomatosis the mucous membrane of cups and a pelvis is surprised, in a cut there is hron, a granulematozny inflammation which is coming to the end with a sclerosis and deformation. See also Shistosomatoza .

P.'s filariasis leads to disturbance of a lymph drainage, hron. to a lymphostasis, hypostasis and sclerous changes (see articles devoted to separate fllyariatoza, e.g. Brugioz , Vukhererioz etc.).

Compensatory and adaptive processes are presented to P. by an atrophy, a hypertrophy, a hyperplasia and regeneration. P.'s atrophy or its parts in one cases arises in connection with insufficiency of blood supply, in others — from pressure in connection with disturbance of outflow of urine from a pelvis. More often insufficiency of blood supply is connected with atherosclerosis of a renal artery and its branches that leads to atherosclerotic nephrosclerosis, or with the hyalinosis of arterioles of P. causing development of an arteriolosklerotichesky nephrosclerosis. Lead to insufficient blood supply and P.'s atrophy also hron, inflammatory and dystrophic processes in renal balls, napr, at hron, a glomerulonephritis, an amyloidosis, a diabetic glomerulosclerosis. P.'s atrophy from pressure is originally characterized piyet an ectasia, further there occurs thinning of brain and cortical substance. In far come P.'s cases macroscopically looks as a thin-walled connective tissue bag (see. Hydronephrosis ).

The hypertrophy can develop both in the whole P., and in its parts. At death or operational removal of one P. another is exposed to a hypertrophy, to-ruyu call vicarious or replaceable; The Item at the same time increases in sizes. In essence the vicarious hypertrophy of P. is similar to the regeneration hypertrophy developing in the remained part P. at its damage. The intracellular hyperplasia, i.e. increase in number of cellular ultrastructures is the cornerstone of a hypertrophy.

PATHOLOGY

Exists several classifications of diseases of P. which are constantly reconsidered. Generally allocate malformations, infectious, fungal, invasive and immune diseases of P. (see the Glomerulonephritis), metabolic to a nephropathy, chemical, radiation injuries (see Nephrite), vascular defeats, P.'s defeats at collagenoses, a nephrolithiasis (see), a nephroptosis (see), cysts and P.'s tumors, a disease of a renal transplant and some other. At many nosological forms, whenever possible, allocate a stage of process (e.g., latent, a stage a wedge. manifestations, an end-stage), a wedge, a form (e.g., proteinuri-chesky, nephrotic or hypertensive) and the course of process (e.g., quickly or slowly progressing, recuring).

Malformations

In the majority of classifications call them anomalies, to the Crimea refer anomalies of an arrangement of P. (allotopia), relationship and forms P., anomalies of quantity, anomaly of a renal parenchyma, pyelocaliceal system and vessels of the Item.

Anomalies of an arrangement (allotopia) are connected with disturbance in the course of an embryogenesis of ascension and P. Razlichayut's rotation gomolate-ralny (thoracic, lumbar, ileal and pelvic) and heterolateral (cross) allotopias.

At a thoracic allotopia of P. usually is a part of phrenic hernia (see. Diaphragm ). The ureter at the same time is extended, the renal artery departs from a chest part of an aorta. At a lumbar allotopia the renal pelvis is a little turned kpered and is at the level of IV of a lumbar vertebra; the renal artery departs from an aorta above its bifurcation.

The ileal allotopia of P. is characterized by more expressed rotation of a renal pelvis of a kpereda and its arrangement at the level V of lumbar — the I sacral vertebrae. Renal arteries, as a rule, multiple, depart from the general ileal artery or from a belly part of an aorta at the level of its bifurcation.

At a pelvic allotopia of P. is located on the centerline, behind and slightly higher than a bladder; it, as a rule, in a varying degree a gipoplazirovana also has the oval, round or square form. By the item it is turned on an axis, the renal pelvis is directed lateralno and forward, and renal cups — medially or back. Vessels of loose type are branches of the general ileal or internal ileal arteries. The Geterolateral-ny (cross) allotopia is characterized by P.'s removal on the opposite side.

Dihundred-pyrobathing P. often has a lobular structure and usually loose type of blood supply with the short vessels limiting its smeshchayemost.

In a wedge, the picture caused by a misplaced of body, the leading symptom is the pain arising at a postural change of a body, physical tension, a meteorism. At a heterolateral (cross) allotopia pain is usually localized in ileal area and irradiates to the inguinal area on the opposite side. At a thoracic allotopia of P. a wedge, manifestations and data rentgenol, researches can remind a tumor of a mediastinum. At a lumbar and ileal allotopia of P. it is palpated in the form of slaboboleznenny slow-moving education.

The diagnosis is established by means of excretory urography (see), and in case of falloff of function P. — a retrograde piyelografiya (see).

Treatment preferential conservative. Operational treatment is shown at the allotopia complicated by a hydronephrosis (see) or a nephrolithiasis (see).

Anomalies of relationship and form. Anomalies of relationship (the spliced kidneys) make apprx. 13% of all renal anomalies. Distinguish symmetric (horseshoe and galetoobrazny kidneys) and asymmetric (S-, L-and I-shaped kidneys) forms of an union.

Symmetric forms of an union. Horseshoe P. meets by 2,5 times more often at boys. It is formed at an union lower (90%) or upper (10%) by poles, and P. takes a form of a horseshoe. On site connections P. there is an isthmus formed by connecting fabric or a renal parenchyma. Horseshoe P. is located below, than usually, a renal pelvis of accrete P. is directed kpered or lateralno. Blood supply is carried out by the multiple arteries departing from a belly part of an aorta or its branches.

Fig. 11. Excretory Urogramum at a fused kidney: a convex part of a kidney is turned down.

The basic the wedge, horseshoe P.'s sign is Martynov's symptom — Rovzinga — the voznikno-noveniye of pains at extension of a trunk connected with a prelum of vessels and an aortal texture an isthmus P. Horseshoe P. sometimes can be revealed at a deep palpation of a stomach as dense slow-moving education. Radiological such P. has an appearance of a horseshoe, a convex part a cut is turned more often down (fig. 11), more rare up. Most accurately horseshoe P.'s contours come to light against the background of pneumoretroperitoneum (see) or at an angiography in a phase of a nefrogramma. On excretory Urogramums horseshoe P. is characterized by rotation of pyelocaliceal system and change of a corner between longitudinal axes of accrete P.: if normal this corner is open from top to bottom, then at horseshoe P. in 90% of cases — up.

Operations at horseshoe P. usually make at development of complications (a hydronephrosis, a tumor, etc.). For the purpose of detection of nature of blood supply before operation carrying out a renal angiography is shown (see).

Galetoobrazny P. has an appearance of the flat and oval education located at the level or is lower about-montoriya (the cape, T.). Anomaly forms as a result of P.'s accretion by both poles prior to their rotation. Blood supply such P. is carried out by the multiple vessels which are departing from bifurcation of an aorta and randomly penetrating a renal parenchyma. A pelvis is turned kpered, ureters are shortened. Diagnosis is based on data of a palpation, a manual rectal research (see), and also results of excretory urography and an abdominal aortografiya. Purulent pyelonephritis, stones, tuberculosis can be a reason for an operative measure. Cases of removal of the galetoobrazny kidney which is mistakenly taken for a tumor are known.

Fig. 12. The diagrammatic representation of kidneys with asymmetric forms of an union: a — a S-shaped kidney — a L-shaped kidney, in — an I-shaped kidney; 1 — a ventral aorta, 2 — the lower vena cava, 3 — ureters, 4 — a kidney.

Asymmetric forms of an union make 4% of all renal anomalies. They are characterized by connection P. by opposite poles (fig. 12). Longitudinal axes P., grown together in the form of armor. the letters S and I, are parallel, and at a L-shaped kidney — are perpendicular each other.

The diagnosis is established at excretory urography and scanning of the Item. In need of operational treatment (a removing calculus, plastics concerning an urinary stasis, etc.) carrying out a renal angiography is shown.

Fig. 13. The diagrammatic representation of kidneys during the doubling of pyelocaliceal system (a), doubling of renal vessels (b) and full doubling of a kidney (); the dotted line showed contours of pyelocaliceal system.

Anomalies of quantity. Doubling of kidneys — the most frequent anomaly of P.; meets twice more often at girls. P.'s doubling happens full and incomplete. Existence of two collective systems P., each of is characteristic of full doubling to-rykh has the isolated blood supply. At incomplete doubling of P. blood supply of its both half is carried out by one vascular bundle (fig. 13). The ureters departing from a renal pelvis of the doubled P. fall into a bladder separately or merge in one trunk. At full doubling of an ureter the main trunk departing from the lower segment of the doubled P. opens in a corner of a vesical (lyetodiyev) triangle, and from upper — distalny, is closer to a neck of a bladder or to an urethra. The parenchyma of the doubled P. has signs of a hypoplasia, a dysplasia that promotes development of various diseases, first of all pyelonephritis (see). At the same time the upper segment P. because of disturbance of outflow of urine in distal department of an ureter (a stenosis, to the ureterotsela, an allotopia of the mouth) and more expressed dysplasia most often is surprised. In the lower segment P. development of pyelonephritis is connected with a reflux of urine.

Anomaly is diagnosed usually at inspection concerning the developing complications. On excretory Urogramums the upper segment can not come to light in view of its functional inferiority therefore at suspicion on P.'s doubling pictures make usually in 2 — 6 hours after administration of contrast medium. At full anatomic and functional inferiority of one or both segments P. make their removal. In case of an incontience of urine owing to an ectopia of the mouth of an additional ureter implant an ureter into a bladder. At a reflux on one of ureters impose uretero-uretero-or piyelopiyeloanastomoz; if there is a reflux in both ureters of the doubled P., then make their submucosal tunnels-zatsiyu one block. In the presence to an ureterotsela make its excision with change of ureters.

Anomalies of a renal parenchyma. Renal ageneses — result of lack of laying of body in the course of an embryogenesis. Bilateral P. (areniya) agenesias is noted 4 times less often unilateral and is preferential at male fruits. Children with a bilateral agenesia of P. usually are born the dead, with the multiple combined malformations: lack of a bladder, a dysplasia of generative organs, it is frequent with a hypoplasia of lungs, spinal hernia. At a unilateral agenesia of P., as a rule, there are no corresponding ureter and a gonad. The only P. is usually hypertrophied and full-fledged in the functional relation. Suspicion of P.'s agenesia arises at the palpation increased painless by the Item. The diagnosis establish on the basis of a tsistoskopiya, excretory Urografinum, a radio isotope research and belly aortografiya (see). At Urografinum on the party of an agenesia of P. there is no release of contrast medium. By means of a tsistoskopiya the hemiatrophy of a vesical (lyetodiyev) triangle and existence of only one ureteric mouth comes to light. Aortografiya points to lack of a renal artery.

An aplasia of a kidney — the heavy degree of an underdevelopment of a renal parenchyma which is quite often combined with lack of an ureter. The item is submitted by fibrolipomatozny fabric, sometimes with a small amount of the functioning nephrons.

Usually P.'s aplasia is not shown clinically and distinguished at diseases opposite to the Item. Some patients show complaints to stitches or a stomach that is connected with a prelum of nerve terminations fibrous fabric and the increasing cysts. Arterial hypertension is in rare instances noted. On the survey roentgenogram sometimes in the field of aplazirovanny P. find cysts with calciphied walls. At an aortografiya in these cases the renal artery usually does not come to light.

Need to lay down. actions at P.'s aplasia arises at sharply expressed pains, development of hypertensia and a reflux in a gipoplazirovan-ny ureter. Treatment operational — aplazirovanny P.'s removal and an ureter.

The Gipoplazirovanny kidney macroscopically looks as normally created body reduced in sizes. Histologically there are changes allowing to allocate a simple hypoplasia, a hypoplasia with an oligonef-roniya and a hypoplasia with a dysplasia. The simple hypoplasia is characterized only by reduction of number of renal cups and nephrons. At a hypoplasia with an oligonefroniya reduction of quantity of renal balls is combined with increase in their diameter, fibrosis of intersticial fabric, expansion of renal tubules. The hypoplasia with a dysplasia is shown by development of connective tissue or muscular couplings around renal tubules, existence of glomerular or canalicular cysts, and also inclusions of lymphoid, cartilaginous and bone fabrics.

The unilateral hypoplasia of P. can clinically not be shown. However in gipoplazirovanny P. quite often there is a pyelonephritis often leading to development of nephrogenic hypertensia. The severe form of a bilateral hypoplasia of P. is shown early — in the first years or even weeks of life of the child. Children lag behind in physical development. Pallor, vomiting, a diarrhea, fervescence, symptoms of rickets are quite often observed. The expressed decrease in concentration function P is noted. Most of children with the expressed bilateral hypoplasia of P. perishes in the first years of life from uraemia (see).

The unilateral hypoplasia is usually revealed at rentgenol, the research undertaken concerning pyelonephritis. On excretory Urogramums reduction of the sizes P. with the system which is well contrasted cha-shechno-lokhanochnoy is noted. P.'s contours can be uneven, the number of cups are less, than normal, their volume is reduced. Opposite P. is kompensatorno hypertrophied. Big help in differential diagnosis is given by an angiography and a biopsy of the Item.

Treatment at the unilateral hypoplasia complicated by pyelonephritis and hypertensia usually comes down to a nephrectomy. At a bilateral grshoplaziya of P. complicated by a heavy renal failure the bilateral nephrectomy (see) with the subsequent transplantation of P. can be carried out (see Renal transplantation).

An accessory (third) kidney — rare anomaly (is apprx. 100 observations). Its education is caused by an otpochkovaniye of a part of a metanephrogenic blastema. Additional P. usually is located below the main, has considerably the smaller sizes and own blood supply at the expense of the vessels departing directly from an aorta. The ureter falls into a bladder independently or the main is reported with an ureter P. Klien, additional P. gains value at a cervical or extracystic ectopia of the mouth of an ureter with a constant incontience of urine or at its defeat by inflammatory or tumoral process. The diagnosis establish on the basis of data excretory Urografinum, a retrograde piyelografiya, aortografiya Treatment consists in a nephrectomy of an accessory kidney.

Fig. 14. The diagrammatic representation of different types of cystous anomalies of kidneys (in black color the chashechnolokhanochny system is shown): and — a polycystosis — a multicystosis, in — a solitary cyst — a multilokulyarny cyst, d — a sponge kidney, in — the chashechkovy diverticulum in an upper pole of a kidney which is reported with pyelocaliceal system.
Fig. A. Fig. 1 — 8. Macrodrugs of kidneys at various diseases and morbid conditions. Cassocks. 1. Polycystosis of a kidney. Fig. 2. Polycystosis of a kidney (frontal section). Fig. 3. Megacalycosis of a kidney. Fig. 4. Hydronephrosis of a kidney (frontal section): in renal cups and a pelvis numerous urinary stones are visible. Fig. 5. Adenocarcinoma of a kidney (frontal section): the tumor of a motley view at the expense of hemorrhages and necroses with existence of cysts of various size burgeoning in the fibrous capsule and perinephric cellulose. Fig. 6. Echinococcus of a kidney: the closed cyst of an echinococcus which is sharply stretching a fibrous renal capsule is visible acting. Fig. 7. Planocellular cancer of a kidney: the tumoral node fills a renal pelvis. Fig. 8. Sarcoma of a kidney (frontal section). Fig. 9. Microdrug of an adenocarcinoma of a kidney: the solid structures formed by polygonal and cubic cells with light cytoplasm, which are located among thin layers of a stroma.

Cystous anomalies of a parenchyma. Among cystous anomalies there are P.'s parenchyma the most frequent — a polycystosis (fig. 14, a) — a polycystic degeneration, a polycystic disease — the hereditary anomaly affecting both kidneys (see. Polycystic dysplasia of kidneys). It is quite often combined with cystous changes of other bodies, napr, a liver, spleens, are more rare than lungs, a pancreas. P.'s polycystosis which is found at adults is transferred is prepotent with an autosomal and monomeric gene, and a so-called malignant polycystosis of children's age — retsessivno. Development of a polycystosis of P. is connected with disturbance of an embryogenesis in the first weeks that leads to nonunion of tubules of a metanephros with collective tubules of an ureteric rudiment. The cysts which are formed as a result of it divide on glomerular, tubular and excretory. Glomerular cysts have no communication with renal tubules, lead to a prematurity of a renal failure. Tubular cysts are formed of gyrose renal tubules, and excretory — of collective renal tubules. These cysts unevenly, but constantly increase in volume in connection with difficulty of emptying. At early children's age of a cyst small, are located as in brain, and cortical substance. Between them the parenchyma without dysplastic changes is defined. At children of advanced age and adult P. are considerably increased, deformed at the expense of numerous cysts of various size (tsvetn fig. A. 1 — 2). Islands of a parenchyma are squeezed by cysts, change-types of intersticial nephrite are quite often noted. At P.'s polycystosis pyelonephritis, a nephrolithiasis, tuberculosis

P. Klien often develops, manifestations of a polycystosis of P. are various in different age groups. The earlier there are its signs, the zlokachestvenny the disease proceeds. At children of early age P.'s polycystosis quite often is complicated by the pyelonephritis which is quickly leading to uraemia. At P.'s polycystosis dull aches in a waist, periodic are noted hamaturia (see), arterial hypertension (see. arterial hypertension ), a polyuria (see), a hypoisosthenuria (see. Isosthenuria ) and nocturia (see). At a palpation the increased hilly Items come to light. Accession of pyelonephritis is characterized corresponding a wedge. manifestations, changes in blood tests and urine and the progressing development of a renal failure (see).

The diagnosis establish by means of excretory Urografinum, radio isotope and ultrasonic investigation and a renal angiography. On Urogramums at the kept function the increased P., lengthening and drawing apart necks of renal cups decide on their kolbovidny deformation. At early stages of process the urografichesky picture can be not indicative. The radio isotope research reveals P.'s increase and defects of a parenchyma in connection with uneven accumulation of radionuclide. Angiographically thinning and depletion of vascular network, drawing apart arterial branches is defined. In a nefrografichesky phase P. has a spotty appearance.

Treatment is directed to fight against pyelonephritis, hypertensia, disturbances of water and electrolytic balance. Often an operative measure at P.'s polycystosis considerably makes heavier a condition of the patient. Nevertheless it becomes necessary at profuse renal bleeding, an occlusive stone, suppuration of cysts, a pyonephrosis, development of a malignant tumor of the Item.

The forecast at P.'s polycystosis is more often adverse. Patients seldom live more than 10 — 12 years after emergence a wedge, symptoms though cases of life expectancy up to 70 years at the high-quality course of a disease are known.

A multicystous dysplasia (fig. 14, b) — anomaly, at a cut usually one or, much more rare, both P. are replaced with cysts and parenchyma are completely deprived. The ureter at the same time is absent or is rudimentary. Bilateral multicystous dysplasia of G1. it is incompatible with life. At hemilesion the wedge, symptoms arise in connection with a prelum cysts of surrounding bodies. In these cases resort to a nephrectomy.

A solitary cyst (fig. 14, c) — single cystous education, coming from parenchyma of II. and acting over its surface. Diameter of a cyst, as a rule, does not exceed 10 cm. The cyst usually contains serous, occasionally hemorrhagic (owing to hemorrhage) liquid. Seldom meets in 11. a dermoid cyst (see the Dermoid).

The most characteristic a wedge, symptoms of a solitary cyst of P. are dull ache in the area P., the palpated tumor and a tranzitorny hamaturia.

In a survey picture at an arrangement of a cyst on P.'s surface the shadow of the roundish education which is intimately connected with the Item is visible. At its arrangement in a parenchyma protrusion of a contour of the Item is observed. At the central localization of a cyst diffusion increase in body is noted. Crucial importance in diagnosis of cysts belongs to contrast methods of a research. At excretory Urografinum establish deformation of pyelocaliceal system, at a nefrotomografiya P.'s cyst comes to light as the roundish, accurately outlined site of an enlightenment. On arteriogramma in a zone of a cyst there is an avascular site with moved apart and the extended branches of vessels which are bending around it thin (see below fig. 24). In a nefrografichesky phase in a projection of a cyst accurately delimited defect of filling is visible. The kistografiya helps with differential diagnosis of tumors and cysts (a transdermal puncture of a cyst with filling of her cavity a contrast agent).

Treatment — operational. If localization of a cyst allows, then carry out its enucleating or open and tampon her cavity pararenal cellulose. The puncture of a solitary cyst with the subsequent filling its sclerosing solution in 50% of cases leads to recovery.

The Multilokulyarny cyst (fig. 14, d) — very rare anomaly which is characterized by substitution of site P. the multichamber, not reported with a renal pelvis cyst. Other part of a parenchyma is not changed and normally functions. With a growth of a cyst it manages to be palpated through a front abdominal wall. On Urogramums defect of a parenchyma with a pushing off or drawing apart renal cups is noted, on angiograms it looks avascular. Need in to lay down. actions arises at development of complications, napr, pyelonephritis. Treatment consists in a segmented resection of P. or a nephrectomy.

Sponge kidney (a medullary cystic kidney, a kidney with spongy pyramids) — quite rare hereditary anomaly, at a cut collective renal tubules are kistozno expanded (fig. 14, e). Items are increased, on their surface there are multiple cysts to dia. 0,1 — 0,2 cm. The polyuria, the Isosthenuria, attacks of renal colic owing to frequent stratification of a kalkulez or pyelonephritis are clinically usually noted.

The diagnosis establish at survey and excretory Urografinum on a typical arrangement in the field of renal pyramids of small shadows of urinary stones and to existence of uviform expansion of collective renal tubules. Treatment is carried out only in case of development of complications.

Anomalies of pyelocaliceal system. A megacalycosis — the dysplasia of renal cups which is followed by their inborn increase (tsvetn. fig. A. 3). The name of anomaly is offered in 1905 to Pyyugvertom (And. Riigvert). At the same time there is an underdevelopment of renal pyramids, flattening of renal nipples in this connection small renal cups gain rounded shape and the increased volume. Usually all cups of P. are surprised, only some are more rare. Extremely seldom the bilateral megacalycosis meets. Stagnation of urine in expanded small renal cups promotes formation of stones and development of pyelonephritis. On excretory Urogramums significant increase in volume, and sometimes and the number of the small renal cups having rounded shape is noted. At the same time the pelvis is not changed, and freely we pass an ureter for a contrast agent.

Treatment is conservative, it is directed to fight against pyelonephritis. At formation of stones make their removal, sometimes with a resection of a pole P.

Chashechkovy a diverticulum (fig. 14, e) — the anomaly for the first time described in 1941 by G. Prather, which is characterized by existence of the cystous education connected with a small renal cup the narrow channel. Usually chashechkovy diverticulum departs from upper group of small renal cups (twice more often on the right, than at the left). Stagnation of urine in a chashechkovy diverticulum quite often leads to development of pyelonephritis and formation of stones. Symptoms of these complications also show a wedge. picture of a chashechkovy diverticulum.

Diagnosis is based on data of excretory urography. In doubtful cases carry out the retrograde piyelografiya allowing to see accurately a cavity of a cyst and the narrow course reporting it with a renal cup. As the most radical way of treatment serves removal of a diverticulum with a resection of site P. The forecast at operational treatment is more often favorable.

Anomalies of renal vessels divide into anomalies of arteries, veins and arteriovenous fistulas.

The agenesia of a renal artery, as a rule, unilateral, is combined with P.'s agenesia and the case on 1000 newborns meets frequency of 1. The bilateral agenesia of a renal artery is incompatible with life. Clinically unilateral agenesia of a renal artery is shown when there are symptoms of defeat only the Item. For diagnosis of this malformation use a renal angiography.

The aplasia of a renal artery is combined with an aplasia of a renal parenchyma. In these cases the renal artery represents connective tissue tyazh with sharply narrowed or obliterated gleam. The diagnosis is established by means of an aortografiya.

The hypoplasia of a renal artery is combined with P.'s hypoplasia or with its polycystic dysplasia. On arteriogramma the hypo-plazirovannaya renal artery is represented shortened and narrowed throughout that distinguishes it from the image of a renal artery at secondary wrinkling of the Item. At a bilateral hypoplasia of a renal artery and kidneys the renal failure can develop (see).

Additional (aberrant) renal arteries meet quite often, on a nek-eye to data, approximately in 30% of cases, but only in nek-ry cases they are followed patol, changes of a renal parenchyma. Additional renal arteries have the smaller diameter of a gleam, than the main trunk of a vessel. Departing from an aorta, the additional renal artery goes to lower or is more rare to an upper pole of the Item. It can squeeze an ureter, causing disturbance of outflow of urine. The diagnosis establish by comparison excretory Urogramum and renal angiograms. Crossing of an additional renal artery at an operative measure can lead to development of a segmented necrosis of a kidney.

A double renal artery — two equivalent trunks of a renal artery, approximately identical caliber. Anomaly gets a wedge, value at operations on P., especially at transplantation of the Item.

Multiple renal arteries krovosnabzhat usually horseshoe or dis-topirovanny the Item. Their number and caliber widely vary that can create great difficulties at operations therefore before intervention on dihundred-pyrobathing P. carry usually out an angiography.

An inborn renal artery stenosis — the concentric arteriostenosis leading to deterioration in a trophicity of P. and development of renovascular hypertensia. It is more often localized near the mouth of a renal artery, but can be located on any its site. Diagnosis is based on data of arteriography and separate determination of content of a renin in the blood flowing from P. Treatment consists in a resection of the narrowed site of an artery or in its prosthetics. In far come cases with the expressed hypertensia resort to a nephrectomy.

Inborn aneurism of a renal artery is observed extremely seldom. Its wedge, manifestations, diagnosis and treatment same, as at a renal artery stenosis. The spontaneous rupture of aneurism with bleeding in retroperitoneal space and an abdominal cavity is possible.

Fibromas a skulyarny dysplasia — the inborn underdevelopment of a muscular coat of an artery with substitution its fibrous tkanyo — develops preferential in an average third of a renal artery, but can be observed on all its extent. Sometimes also additional renal arteries are surprised. The wedge, signs in the form of renal hypertensia and a hamaturia appear usually at children's age. Establishment of the diagnosis is helped by a belly aortografiya and the selection renal arteriography. Treatment consists in prosthetics of a renal artery.

The ring-shaped renal vein meets only at the left that is caused its more difficult, than on the right, by an embryogenesis and an arrangement. The ring-shaped vein is presented by two branches: the lobby passes as usual, back goes slantwise down, bypasses an aorta behind and falls into the lower vena cava at the level of III — the IV lumbar vertebrae. The prelum of one of trunks leads to congestive renal venous hypertensia that can be shown by an albuminuria, a hamaturia, a varicosity of the left seed cord. Anomaly is distinguished by means of a venoka-vografiya and the selection renal venografiya. In cases of the expressed venous hypertensia resort to the operation offered H. A. JIo-patkin — to imposing of an anastomosis between left yaichkovy and the general ileal veins.

The retroaortal left renal vein departs one or, more rare, neskolshsh trunks. It goes slantwise down, passes behind an aorta and falls into the lower vena cava at the level of II — the IV lumbar vertebrae. Klien, manifestations, diagnosis and to lay down. tactics are identical to that at a ring-shaped renal vein.

Ekstrakavalny confluence of the left renal vein is much less often observed, is more often in the left general ileal vein. It complicates venous outflow of blood from P. in view of more high pressure in the general ileal vein, than in the lower hollow. Diagnosis is based on data of a venokavografiya. Treatment is same, as at a ring-shaped renal vein.

Inborn arteriovenous fistulas serve one of the reasons of venous renal hypertensia. They can be localized on any site of a vascular bed of II. also are distinguished by means of the selection renal angiography. Treatment consists in imposing of a re-nokavalny venous anastomosis.

Damages

P.'s Damages are more often observed at men of young and middle age, 10 — 12% of all damages fall to the share of children P. Pravaya and the left P. are damaged equally often; both P.' damage meet seldom.

Distinguish the opened and closed damages of the Item. Open damages (wounds) of P. are observed seldom. They can be fire and put with the pricking or cutting tool. Distinguish not getting (tangents) and getting (through and blind) wounds of the Item.

The closed P.'s damages are possible as in the conditions of peace, and wartime. Patients with the closed P.'s damages would make in ambulance 1,3% of all stationary traumatologic patients and 2,5% the Urals, patients. On the isolated P.'s damages 65%, are the share of the combined damages of P. and other bodies — 35%.

Fig. 15. The roentgenogram (a retrograde piyelografiya) of a right kidney and ureter at damage of a renal pelvis by an ureteric catheter: by shooters it is specified flowed a contrast agent out of limits of a contour of a kidney.
Fig. 16. Excretory Urogramum at subkapsulyarnom a rupture of a right kidney: the arrow specified shapeless flowed a contrast agent into a parenchyma of a kidney.

On the mechanism of damage of P. distinguish: concussion (when the injuring force did not affect directly area P.), single-step blows to the area P. or counterstrokes, a prelum and stretching of area P. P.'s damages can arise in case of bystry introduction to a renal pelvis of excessive quantity of contrast medium at a retrograde piyelografiya. At the time of catheterization there can be a perforation a catheter patholologically of the changed renal pelvis or an ureter (fig. 15). At concussion, napr, during the falling from height, influence of a blast wave, there are intra renal hemorrhages (fig. 16), subkapsulyarny cracks and is rare — ruptures of body together with the capsule. At single-step blows, napr, a bumper of the car, falling side on the acting subject, etc., ruptures of a renal parenchyma are possible, it is frequent with damage of the fibrous capsule P., sometimes getting into pyelocaliceal system. The prelum or stretching of area P. at hit under wheels of vehicles, compression between buffers of cars, a pridavlivaniya to a wall, etc. usually causes rough damage of P. (crush, a separation, crush, a fragmentapiya). According to Tyuffye (M. Th. Tuffier), the closed P.'s damage is caused by infringement it between XI, XII edges and a backbone. E. G. F. Kuster considered that he for P.'s damage has special value the hydrostatic pressure of liquid in it. A. P. Frumkin and G. P. Kulakov explain P.'s rupture with sharp reduction of lumbar muscles and vyvikhivaniy P. from a renal bed. Rate of decay of P. depends not only at most and the nature of the injuring influence, but also age of the victim, a condition of hypodermic, pararenal cellulose and muscles, filling of intestines, intra belly pressure preceding an injury patol, changes of body. An important role is played by also anatomic features, including a form P. and type of branching of renal vessels. Are steadiest against P.'s injury with an extrarenal pelvis and blood supply on the main type. P. with an intra renal pelvis and loose type of front and back branches of renal arteries are easier injured. Ruptures of renal fabric occur usually in intersegmental low-vascular zones, and large arterial vessels of P. are damaged seldom.

Fig. 17. The diagrammatic representation of the closed injuries of kidneys of various degree on Kyuster's classification (contours of pyelocaliceal system are shown by a dotted line): and — damage of fatty and fibrous renal capsules is specified by an arrow), the I degree; — the rupture of a parenchyma (1) which is not getting into pyelocaliceal system of a kidney, and formation of a subcapsular hematoma (2), the II degree; in — the rupture of a parenchyma (is specified by an arrow) getting into pyelocaliceal system of a kidney, the III degree; — crush of a kidney with a gap on fragments, the IV degree; d — a full separation of a kidney with a rupture of renal vessels and an ureter, the V degree.

According to Kyuster's classification, distinguish the following damage rates (fig. 17): I) damage of the adipose and fibrous capsule P. with formation of a hematoma in perinephric cellulose; II) ruptures of a parenchyma of II., not getting into renal cups and a pelvis, and also subcap-sulnye and pararenal hematomas; III) the ruptures of a parenchyma getting into renal cups and a pelvis at to-rykh in pararenal cellulose stream blood, urine and the urohematoma is formed; IV) P.'s crush with a gap it on small fragments which is followed by formation of an urohematoma; V) damage of renal vessels and a full separation of P. with formation of an extensive hematoma. As a special type of damage sometimes allocate quite often found P.'s bruise, at Krom hemorrhages in a renal parenchyma without macroscopic signs of its gap are noted.

The main symptoms of damage of P. are pain, a swelling in the field of their arrangement (A pararenal hematoma or an urohematoma) and a hamaturia, and at open damages — and release of urine from a wound. However all these symptoms meet not always. The hamaturia — the most constant and characteristic symptom which is observed in 95 — 98% of cases of damages of P. Gematuriya can be absent at a separation of vessels of P., an ureter or ureteral occlusion a clot. Intensity of a hamaturia does not define a damage rate of P., however the long profuse hamaturia is a terrible sign.

The pararenal hematoma and an urohematoma are palpated, according to various data, with P. Inogd's damage the hematoma manages to be found in 5 — 15% of patients only on 2 — the 3rd days after an injury. The considerable Pararenal hematoma is followed by symptoms of irritation of a peritoneum. Bol is caused not only P.'s damage, but also the combined injury of edges or other bodies which can shade a picture of a typical pain syndrome at an injury of the Item. The isolated P.'s damages, and it is frequent and the combined injuries are not always followed by shock. At ureteral occlusion renal colic can be observed by clots. Accumulation in a bladder of clots can cause the dysuric phenomena and a tamponade of a bladder. At patients with heavy damages of P. and the combined injury in the first 5 days the oliguria (see), in case of an injury of both P. or the only functioning P. is observed, and also at heavy shock the anury can develop (see). In the first 3 days fervescence is observed that, however, does not indicate weight of an injury and is not a symptom of acute traumatic pyelonephritis. The last develops at 15 — 20% of patients with P.'s damages; it is diagnosed on the basis of long fever, existence of a leukocyturia (see) also by bacteriurias (see). Klien, picture of the combined damages of P. is more diverse that complicates diagnosis. It is especially difficult to diagnose the combined damages of P. and abdominal organs. At the same time pain and a muscle tension of a front abdominal wall quite often extend to all stomach, at percussion of a stomach existence in an abdominal cavity of free gas or liquid comes to light. Jaundice and substantial increase of content in blood of zymohexase and transaminases are characteristic of the combined damages of P. and a liver.

The diagnosis of the closed P.'s damage is established on the basis of the given the anamnesis, local and general symptoms. The damage rate of body is specified by means of survey and excretory urography (see), a retrograde piyelografiya (see), a renal angiography (see), by scannings (see), an isotope stsintigrafiya (see), a computer tomography (see the Tomography computer). On the survey roentgenogram it is possible to find injury of bones, a rachiocampsis, lack of a contour of a big lumbar muscle and P.'s contour on the party of damage at a retroperitoneal hematoma. On excretory Urogramums at sub-kapsulyarnykh damages (bruises and ruptures of a parenchyma) the slowed-down release of contrast medium of the damaged P. is noted, sometimes it is possible to notice protrusion of a contour of P., a prelum or deformation of renal cups, flow a contrast agent from renal cups into a parenchyma, not getting, however, out of limits of the Item. Such subkapsulyarny damages to the kliniko-anatomic relation can be classified as damages of the I degree. Damages of the II degree are characterized, besides, by existence of a considerable pararenal hematoma owing to a rupture of the fibrous capsule and a parenchyma of P. which is not extending, however, to pyelocaliceal system. The existence on Urogramums or a retrograde piyelogramma of zatek of a contrast agent in pararenal cellulose caused by a complete separation of body and damage of pyelocaliceal system is characteristic of damage of the III degree (damage with an urohematoma). P.'s crush and a separation from a renal leg carry it respectively to IV and V damage rates. Along with critical condition of the patient, falling of arterial pressure, frequent pulse, quickly accruing pararenal hematoma and anemia by means of excretory urography reveal lack of the function damaged by the Item. Function of Kidneys can be absent also at a slight injury if the renal pelvis and an ureter are the corked clots, but in this case the wedge, a picture of renal colic is observed characteristic (see the Nephrolithiasis). In doubtful cases there is a need for a retrograde piyelografiya, and sometimes and a renal angiography. Scanning or a radio isotope stsintigrafiya allow to reveal the defect of accumulation of radio pharmaceutical drug corresponding to the site of damage.

At open damage of P. release of urine from a wound sometimes joins local symptoms (a hamaturia, an urohematoma and pain). For specification of rate of decay of body the same diagnostic methods are used, as at the closed P. V injuries diagnosis of the combined damages of P. and abdominal organs is helped sometimes by a laparoscopy (see. Peritoneoskopiya ).

Treatment of the closed P.'s damages depends on their weight and a combination to an injury of other bodies. At the small isolated damages conservative treatment is shown; high bed rest not less than 2 weeks, haemo static and antibacterial therapy. However at a considerable subkapsulyarny hematoma, edges it is long does not resolve and causes a prelum and the ischemia of a renal parenchyma revealed at repeated excretory urography or a renal angiography, there can be a need for operational removal of a hematoma.

The rupture of a parenchyma of P. (damage of II and III degrees) diagnosed clinically, radiological or scintigraphically is the indication to operativtsy treatment. Operation shall be organ-preserving: delete a pararenal hematoma or an urohematoma, sites of a parenchyma with the broken blood supply (a resection of body), make sewing up of gaps, drain retroperitoneal space. A pyelostomy (see) it is necessary only in the presence of an infection or incomplete confidence in a hemostasis. Even at big cross gaps from convex edge to P.'s gate if blood supply of the broken-off parts is kept, organ-preserving operation is possible.

At the pararenal hematoma increasing in sizes with the accruing anemia operation is performed according to vital indications. Such patient carry out excretory Urografinum) for establishment of a damage rate of P. and identification of a functional state opposite to the Item. The menacing bleeding is observed usually at P.'s crush, its separation from a renal leg. In such cases if opposite P.'s function is not broken, shown a nephrectomy (see). Attempts of organ-preserving operations (Omentorenopexy of the damaged P., sewing together of a vascular leg) are justified only at damages only or only functioning the Item.

At damage abnormal or patholologically the changed P. if the body has sufficient functional capacity, organ-preserving operation is justified (except ruptures of P. caused by tumoral process). Such operations are especially necessary at an injury against the background of the diseases which are followed by bilateral defeat of P. (a polycystosis, a bilateral hydronephrosis, a nephrolithiasis), a spontaneous rupture of P. at patients with hemorrhagic fever with a renal syndrome, a spontaneous rupture of a renal transplant and at patients with damage only the Item.

At the isolated P.'s damage apply Extra peritoneal lumbar access according to Fedorov. At the combined damage of P. and abdominal organs make a laparotomy (see). At any access drainages from P. remove outside out of-bryushinno and carefully isolate from an abdominal cavity. P.'s wounds always demand urgent operation, character a cut (a nephrectomy, P.'s resection, sewing up of a renal wound) finally is defined at audit of the Item. As open damages of P. are always infected, at organ-preserving operations imposing of a piyelos-toma is necessary. Treatment of tool damages of P. usually conservative, but at massive bleeding can arise need for the emergency operational treatment.

The research of a daily urine, products of a nitrogen metabolism, electrolytes of plasma, acid-base equilibrium, koagulogramma and enzi-mogramma gives information on a condition of a homeostasis at P.'s damages, signals about vozkhmozhny complications and helps to korrigirovat treatment. The active surgical tactics based on use of objective diagnostic methods allows to keep in most cases the functioning body and to avoid death by the damaged P. from posttraumatic complications.

From early complications the greatest danger is constituted by secondary bleedings, thrombosis of a renal artery or its branches with development of a heart attack of P., fibrinferments of a renal vein, formation of arteriovenous fistula and false aneurism of a renal artery. In recognition of the last the main place belongs to a renal angiography.

Infection of a hematoma conducts to to a paranephritis (see). Late complications are posttraumatic cysts of P., a hydronephrosis (see), a nephrolithiasis (see the Nephrolithiasis), nephroptosis (see), hron. pyelonephritis (see). Many of these posttraumatic complications can be followed by nephrogenic hypertensia (see arterial hypertension). Medical examination of the persons who transferred injury of a kidney of any degree promotes early identification of posttraumatic complications and their timely treatment.

Treatment of complications operational. It is necessary to carry out nephrectomies more often).

The forecast at the isolated P.'s damages for life favorable on condition of their timely recognition and treatment. Function by the injured P. depends on weight of its damage, possible complications and degree of the subsequent nephrosclerosis (see). At an injury of P. which is combined with injuries of abdominal organs, the forecast considerably worsens.

Features of fighting damages, stage treatment. Fighting damages of P. subdivide on opened and closed. Depending on features of damage they can be isolated, combined or combined. Besides, they are subdivided depending on a type of a hurting shell (bullet, fragmental, etc.), quantities of wounds (single or multiple), the parties of damage (right-or left-side, bilateral), the fields of damage (a pole, a body, P.'s gate). Distinguish the following injuries of P.: the bruises, gutter, nonperforating or through wounds of P. which are not reported or reported with renal cups and a renal pelvis, the ruptures of a parenchyma which are not getting or getting into renal cups and a pelvis, P.'s crush, wound or injury of a vascular leg. In the period of the Great Patriotic War to 95 — 97% of injuries of P. it was the share of open damages.

Fig. 18. Macrodrugs of kidneys at fighting damage: and — the closed damage of a right kidney with the numerous ruptures of a parenchyma having uneven, rough edges; — a missile gutter wound of a left kidney with multiple slit-like ruptures of a parenchyma at the edges.

Pathoanatomical changes in the damaged P. are extremely various: from insignificant hemorrhages at bruises to a rupture of II. on a large number of fragments (fig. 18). The pathoanatomical characteristic of an injury depends on quantity, the sizes, weight, a look, a form and speed of a hurting shell, and also on that, are damaged or large vessels of P. are not damaged whether the wound channel with renal cups and a pelvis is reported. The wound channel, especially at getting P.'s wounds, gets the fancy direction and a form. Three zones are characteristic of a bullet wound of P.: primary wound channel, contusion and molecular concussion. P.'s defeat by the sovre-hmenny firearms having high initial velocity of flight of a bullet causes in it heavy gaps, splitting and crush of fabrics. Damages of vessels promote development of a necrosis of a parenchyma; the damaged vessels are larger, the zone of a necrosis is more extensive. Unlike the closed damages of wound of P. are always infected.

On a wedge, to manifestation and the course of damage of P. can be lungs (bruise), moderately severe (the nonperforating and through wounds which are not reported with a renal pelvis) and heavy (the wounds which are reported with a renal pelvis, damages of large vessels, crush, P.'s separation from vessels and an ureter). Treat the main symptoms of wound of P.: a hamaturia, pains in a waist, the Pararenal hematoma, an urohematoma, release of urine from a wound. The hamaturia as the most reliable symptom of an injury of P. can be absent both at lungs, and at heavy (P.'s separation from a vascular leg) wounds. Less characteristic symptoms are an arrangement of inlet opening at nonperforating wounds and the direction of the wound channel at through wounds, a protective muscle tension of a stomach on the party of damage.

The diagnosis of wound of P. is made on the basis a wedge, signs of damage, and at an opportunity — results of special methods of a research (tsistoskopiya, hromotsistoskopiya, Urografinum, the ascending ureteropiye-lografiya, a piyelografiya, a fistulogra-fiya, etc.).

The first and pre-medical help at P.'s wound includes: imposing on a wound of an aseptic bandage, administration of anesthetics and cardiacs with the subsequent direction of the wounded on PMP. On PMP where give the first medical assistance struck, being in a serious condition, according to indications hold antishock events. In cases of an acute ischuria she is brought a catheter or by means of a suprapubic capillary puncture. Before evacuation correct a bandage, enter anesthetics, antibiotics, antitetanic serum and tetanic

allocate with anatoksinony V MSB in the course of medical sorting the following groups of wounded: agoniruyushchy (are subject to a symptomatic treatment), with the proceeding massive bleeding (need immediate operational treatment), in state of shock (need antishock therapy with the subsequent solution of a question of the place and the nature of operational treatment), wounded in satisfactory condition (are evacuated to destination in specialized to lay down. institutions). To the Urals, departments of hospitals they are given the surgical help corresponding to the nature of damage and carry out treatment in full; besides, perform prevention and treatment of complications — uric fistulas, phlegmons, uric zatek, pyelonephritis, etc.

In the conditions of GO will preferential come to OPM injured with the closed damages of the Item. After rendering the first medical assistance (except the persons which are in state of shock to-rykh send to antishock chamber) they are evacuated in (departments) of hospital base which are pro-thinned out-tsy where carry out specialized medical aid.

Specialized medical aid includes rendering the surgical help, prevention and treatment of complications, performing recovery surgeries.

Diseases

Disturbance of blood circulation can be connected with local changes in P.'s vessels (aneurism of a renal artery, a stenosis of a renal vein, etc.) and general diseases, napr, cardiovascular system, etc. Distinguish arterial and venous disturbances of blood circulation in P. caused by the inborn and acquired changes of renal vessels. They can develop sharply or gradually.

Inborn changes of arteries of P. — see above Malformations. The acquired changes of renal arteries arise at atherosclerosis, a nephroptosis, fibrinferment or an embolism of a renal artery, etc. To the most characteristic the wedge, a symptom at the same time is arterial hypertension, edges meets in 60 — 85% of cases; it is characterized by a malignant current and high figures of diastolic pressure. Besides, macro - or a microhematuria can be observed. At the renal artery stenosis caused by a nephroptosis back pains, especially in vertical position of the patient are noted. At auscultation approximately in 50% of cases in the field of an epigastrium systolic noise is listened. At a research of an eyeground the angiospastic retinopathy is observed (see). Sometimes hyperglobulias take place (see). At a radio isotope renografiya in case of hemilesion of a renal artery find asymmetry renogramm. The diagnosis of damage of a renal artery establish with the help rentgenol, methods of a research (survey and excretory Urografinum, a renal angiography).

Fig. 19. A renal arteriogramma at sacculate aneurism of the right renal artery: aneurism is specified by shooters.

In case of calcification of a wall of aneurism of a renal artery she can be visible on the survey roentgenogram in the form of a ring-shaped shadow. The crucial role in diagnosis of diseases of a renal artery belongs to renal arteriography. Atherosclerotic plaques usually are located in a renal artery closer to an aorta, the fibromuskulyarny dysplasia is localized distalny and creates a picture of chetkoobrazny narrowing on the angiogram. Spindle-shaped or sacculate expansion of the main trunks of a renal artery is defined at its aneurysm (fig. 19).

Thrombosis of a renal artery arises as a complication of sepsis, rheumatism, atherosclerosis, an idiopathic hypertensia, as a result of an injury or damage of a vessel during operation and leads to development of an arterial heart attack of P. Proyavlyaetsya of fibrinferments of a renal artery by sudden sharp pains in lumbar area and in a stomach, rise in body temperature, sometimes vomiting, a delay of a chair, a hamaturia, an oliguria, a proteinuria. In blood the moderate leukocytosis, and with 3 — — the accelerated ROE is noted the 4th day. Sharply activity of transaminases increases. On excretory Urogramums function P. is absent (a total heart attack) or is sharply reduced at not changed configuration of pyelocaliceal system. Absence or depression of function of P. is defined also on a renogramma, defect of the functioning fabric P. comes to light during the scanning and a dynamic stsintigrafiya of the Item. On renal arteriogramma at thrombosis or an embolism of a large trunk of a renal artery the picture of its amputation is noted or in a zone P. the avaskulyarny zone is visible a cone-shaped form.

Treatment, irrespective of the nature of damage of a renal artery — operational. The purpose of operation — recovery of normal main blood circulation in the Item. Operational removal of blood clot of a renal artery can be effective not later than in 2 hours from the moment of development of symptoms of thrombosis. At an atherosclerotic stenosis carry out a chrezaortalny endarteriektomiya (atherosclerotic plaques delete through a section of an aorta), an endarteriektomiya with plastics an autogenic vein or synthetic material more often. At aneurism or a fib-romuskulyarny dysplasia make a resection of an artery with imposing of an anastomosis the end in the end or autotransplantation by the arterial transplant taken from a deep artery of a hip. Apply also imposing of a bypass anastomosis between an aorta and a renal artery from a gomovena, heterograft or a synthetic prosthesis. At damage of the left renal artery the splenorenalny anastomosis is possible. Sometimes at a stenosis or occlusion additional or one of branches of a renal artery the resection of the Item is possible. At the renal artery stenosis caused by atherosclerosis or a fibromuskulyarny dysplasia apply transdermal transluminal rentgenoendo-vascular dilatation of renal arteries by means of a balloon catheter. Some corrective operations on arterial vessels of P. with use of the microsurgical equipment carry out ekstrakorporalno in the conditions of a hypothermia and (or) the isolated perfusion of body with the subsequent autotransplantation of P. (see Blood vessels, Microsurgery).

The inborn or acquired stenosis of a renal vein and arteriovenous fistulas (aneurysms) belong to the damages of renal veins which are followed by venous hypertensia in P. Clinical displays of venous hypertensia in P. are fornikalny renal bleedings (a micro or gross hematuria), a proteinuria, to the varikotsela, a dysmenorrhea. In 50% of cases at a stenosis of a renal vein the hamaturia spontaneously stops since gradual development of collateral circulation reduces venous stagnation in the Item.

Fig. 20. A renal venogramma at a stenosis of branches of the left renal vein: the trunk of the left renal vein (i) and a vein of a small egg (2) are sharply expanded.

In diagnosis of defeats of venous system P. the angiography has major importance (see. Renal angiography). It is begun with carrying out a serial aortografiya (see), to-ruyu carried out in horizontal and vertical provisions of the patient. Signs of a fistulous blood-groove, patol, P.'s mobility, narrowing of a trunk, development of collaterals and other signs of venous stagnation come to light. The selection renal venografiya specifies these aortografiya and finds signs of the broken venous outflow (fig. 20). Completes a research a venotonometriya in the renokavalny intersection.

Treatment: at a hamaturia — a bed rest, haemo static and antihypertensives, intrapelvic introduction of vasoconstrictors. At frequent repeated bleedings carry out operational treatment — recovery of passability of a renal vein, improvement of roundabout venous outflow (fathers-in-law-kuloiliakalny or testikulosa-fenny a venous anastomosis). At arteriovenous aneurisms whenever possible carry out P.'s resection or nephrectomies).

Thrombosis of a renal vein arises sharply — begins an attack of the pains in lumbar area which are followed by a hamaturia, an oliguria, fervescence. As a result of venous thrombosis the venous heart attack of P. proceeding heavier than arterial develops. At this P. it is increased, strained, sharply painful at a palpation. The phlebectasia of a front abdominal wall and a seed cord can be noted. Data of excretory urography confirm absence or falloff of the function struck with the Item. At inefficiency of anticoagulating and fibrinolitic therapy operational treatment — Ektomiya's blood clot (see) or a nephrectomy is shown.

Inflammatory infectious diseases of kidneys divide on an etiology on nonspecific and specific, on a current — on acute and chronic. Among nonspecific inflammatory diseases of the most frequent is pyelonephritis (see) — an inflammation of preferential intersticial fabric with involvement in process of a parenchyma of the Kidney and disturbance of their function. Beginning more often with an acute serous inflammation, this disease at the highly virulent infection broken to urodynamic passes into 1/3 cases in heavier purulent pyelonephritis. Its forms are apostematous nephrite (see) — miliary abscessing of P. as a result of hematogenous planting by bacterial microemboluses; P.'s abscess having also metastatic origin, which is quite often combined with a necrosis of renal nipples (see. Renal nipples necrosis ); an anthrax of a kidney — focal it is purulent - the necrotic process which is followed by extensive inflammatory infiltration of a kidney.

The anthrax of a kidney in 65% of cases happens single, is located more often on the right. Its preferential localization — upper or lower poles of a kidney. The huge anthrax occupying almost all with the Item meets. Infection happens hematogenous, more rare in the ascending way. Developing of an anthrax is explained with an arterial thromboembolism and education in P. of the infected heart attacks. Nekrotizirovanny fabric is exposed to purulent fusion; abscesses, merging among themselves, form the large infiltrate squeezing renal vessels, renal cups and a pelvis. Purulent exudate can break in one of renal cups or via the fibrous capsule P. — in perinephric cellulose with development of a paranephritis (see).

Clinically at the beginning of a disease fever, a headache, nausea, vomiting, perspiration, herpetic rashes, prostration are noted. Oznoba repeat, but then temperature becomes constantly raised, the liver and a spleen increase, jaundice develops. Sometimes at the very beginning of a disease infectious and toxic shock develops (see). Locally reveal a back pain, irrad feasting under a shovel, in hypochondrium, ileal area; muscle tension of a back and stomach, scoliosis, paresis of intestines. The dysuria, a leukocyturia, a hamaturia, an oliguria are possible.

At development of a paranephritis inflammatory infiltration of soft tissues of lumbar area and a contracture of a big lumbar muscle can be noted (psoas symptome). From other complications are possible peritonitis (see), subphrenic abscess (see), an empyema of a pleura (see Pleurisy), intestinal fistula (see), pancreatitis (ShM.), an acute renal failure (see).

In blood test reveal the accelerated ROE, a hyperleukocytosis, sometimes a leukopenia. The analysis of urine indicates leukocyturias), a hamaturia, high degree of a bacteriuria. The uric deposit is changed slightly at the broken outflow of urine on the party of defeat. Biochemical, the blood analysis indicates a renal failure, an intravascular hemolysis, a coagulopathy, giperfermentemiya). By means of a hromotsistoskopiya specify on what party defeat is localized. At a survey X-ray analysis P.'s increase, its shift, restriction of mobility, an illegibility of a contour of a big lumbar muscle, scoliosis, sometimes accumulation of gas in P.'s projection of willows to pararenal cellulose can be noted. On excretory Urogramums and angiograms find protrusion of a contour of P., defect of a parenchyma in the field of infiltrate, deformation of the vascular drawing. By means of a retrograde ureteropiyelografiya find a prelum and deformation of renal cups, their amputation or shift, an additional shadow of a cavity in a peripheral zone P. in case of opening of an anthrax in a renal cup.

Patients with purulent pyelonephritis and P.'s anthrax are subject to the emergency hospitalization and intensive antibacterial treatment on condition of effective drainage struck with the Item. At not stopping - sya process or strong indications of local suppuration operational treatment is shown. Under the general anesthesia make a lumbotomy (see), decapsulations) kidneys (see), emptying of abscesses, P.'s drainage (see Drainage) and retroperitoneal space. At extensive destruction of P. if function other P. is kept, make nephrectomies). The acute renal failure is not a contraindication for operation. Considerable disturbances of a homeostasis before operation can be eliminated with a hemodialysis (see). Treatment by dialysis if necessary can be continued in the postoperative period.

The forecast at purulent pyelonephritis and P.'s anthrax remains serious even at intensive antibacterial and operational treatment, the lethality reaches 20%. After the postponed anthrax of II. pyelonephritis with arterial hypertension or formation of urinary stones is possible hron.

Damage of kidneys at a mephitic gangrene. P.'s gangrene, or renal emphysema — a peculiar form of purulent pyelonephritis, edge meets hl. obr. at the combined wound of P. and intestines. Infestants are pathogenic clostridiums, anaerobic cocci, intestinal gas-producing bacteriums. The disease proceeds with the expressed intoxication. In fabric P. and in pararenal cellulose on the survey roentgenogram accumulations of vials of gas are found.

Treatment — operational (a nephrectomy and broad drainage of retroperitoneal space), supplemented by purpose of antishock, antibacterial agents, use of hyperbaric oxygenation (see). The outcome of a disease in many respects depends on timeliness of complex treatment.

Items are surprised in all cases of anaerobic sepsis. The inflammatory and necrotic changes in renal tubules and an interstitium developing at the same time are a consequence of shock, toxaemia, massive intravascular hemolysis, coagulopathy. Due to the high haemoglobinaemia (see) and a bilirubinemia (see. Hyperbilirubinemia ) skin and scleras get brown coloring from patients. There are a morbidity of muscles, plentiful hemorrhagic herpes, the liver and a spleen increase, bleeding is observed. Shock is aggravated by the accruing anemia and insufficiency of bark of adrenal glands. Nevertheless the condition of patients remains potentially reversible. The complex is shown to lay down. actions, including antishock means (see. Shock ) and urgent operational treatment, exchange krovo-and plazmozameshcheniye, hemosorption (see), a hemodialysis (see), correction of a hemostasis and fibrinolysis, administration of antibacterial agents. At the choice and dosing of antibacterial agents consider weight of an infection and defeat of a gyuchka.

A septicaemia (see. Sepsis ), caused by staphylococcus, gram-negative (escherichias, proteas, a klebsiyella) bacteria, causes P.'s damages, the type and origins to-rykh are extremely variable. Patients with a severe form of a septicaemia make apprx. 30% of the patients with an acute renal failure needing treatment by dialysis. At this category of patients the phenomena of a tubulonekroz and a tubulorrhexis, inflammatory infiltration an interstitium prevail. In other cases various glomerular defeats prevail. Very hard obstructive proceeds I suck - d isty type of defeats, the main sign to-rogo are the necrosis of cortical substance and heart attacks of the Item. A cortical and tubular necrosis are a consequence of bacterial toxaemia (see), shock action the cut is implemented through disturbance of system and renal circulation. At the same time activation of reninangiotenzinovy, hemocoagulative systems and systems of biogenic amines (serotonin, a histamine, kinina) matters.

Clinically renal manifestations of a septicaemia can proceed as an acute renal failure, at a cut infectious shock and a hypovolemia are shown by an oliguria, an anury, water and electrolytic disturbances, acidosis, signs of an intravascular hemolysis, anemia. Recovery of function P. happens later 2 — week, at the same time the polyuria is observed. In the period of an anury the hemodialysis is shown. The acute renal failure at a cortical necrosis is a little reversible and often passes in chronic that demands replaceable dialysis treatment and P.

Septitsemiya's transplantation, caused by golden staphylococcus, has the features since occurs preferential at patients with heart diseases, after endoprosthesis replacement of heart and vessels, at a thrombendocarditis. Morphologically in renal balls reveal exudative and proliferative changes, sometimes with ekstrakapillyarny a component, and ekstramembranozny deposits inherent to this form. Clinically observe a nephrotic syndrome (see). Treatment is directed to a basic disease.

The subacute bacterial endocarditis in 80% of cases is followed by symptoms of defeat of P., and in 10% of cases — a renal failure. Changes in P. are result of a bacterial and aseptic embolism and an infartsirovaniye of renal balls with development in them inflammatory and necrotic changes, infiltration of intersticial fabric, deposits of deposits. The proteinuria, a hamaturia, a nephrotic syndrome are combined usually with other displays of this serious illness. Treatment of an endocarditis promotes involution of manifestations of a glomerulonephritis though the absolute recovery does not occur.

Chronic sepsis. It is long the existing bacteremia inevitably causes changes in the Item. In most cases there is a diffusion glomerulonephritis (see) with mezangialny proliferation. Also lobulyarny and ekstrakapillyarny nephrite meets. In all cases the subendotelial-ny deposits testifying about immunopatol come to light. nature of defeat. The disease is followed by fever, anemia, a lose of weight, a polyarthralgia, gepatospleno-megaliy, limfoadenopatiy. On this background the nephrotic syndrome or the isolated proteinuria, a hamaturia, and also a renal failure can join that is followed by a gipokomplementemiya, giperimmunoglobul an inemiya, circulation in blood of cryoglobulins and a rhematoid factor. For successful treatment of a glomerulonephritis an indispensable condition is elimination of bacteremia.

Damage of kidneys at infectious diseases. Items are involved in patol, process at many inf. diseases. Among them there is a group acute and chronic inf. diseases, at to-rykh renal complications are especially frequent. The hemorrhagic nephrosonephritis, ikterogemorra-gichesky hay fever, salmonellosis, cholera, malaria, scarlet fever, tuberculosis, some mycoses, leprosy, sarcoidosis concern to them.

A hemorrhagic nephrosonephritis (see), or hemorrhagic fever with a renal syndrome — a natural focal disease of a virus etiology, almost in all cases the causing damage to the Item. Moderately severe defeats and heavy make about 40% of cases. In the period of fever and shock in P. take place staz blood in renal balls, hemorrhages in a yukstamedullyarny zone and renal pyramids, ischemic heart attacks, a necrosis and hyaline and drop dystrophy of an epithelium of renal tubules. In a pathogeny of defeat changes of vessels, disturbance of permeability and circulation with ischemic and inflammatory changes in kidneys are essential. At the heavy course of process there are fever, intoxication, shock, haemo concentration, pathological bleeding. The anury developing by the end of the feverish period proceeds sometimes up to 7 — 10 days. Recovery of a diuresis happens violently, the polyuria can reach 10 l. As complications of a disease are possible hemorrhage in a hypophysis, gastrointestinal bleeding, a rupture of a kidney, consecutive infection. Treatment of patients with a severe form of a disease includes use of a hemodialysis. P.'s rupture and the menacing bleeding serve as the indication for operation of sewing up of P. and removal of a hematoma.

The Ikterogemorragichesky hay fever at a half of patients is followed by P.'s defeat, and the acute renal failure develops in 10% of cases. It are the reasons the tubulointersti-tsialny damage caused by a toxaemia and shock. The disease is shown by fever, jaundice, a gepatosplenomegaliya, a cardiopathy, bleeding, a sopor. The anury arises from the first days of a disease and proceeds week and more in this connection in a complex to lay down. actions include a hemodialysis. Function P. at a favorable outcome is recovered. See also Lea tospiroz.

Malaria causes acute and hron, changes in P., character and a current to-rykh depend on type of the activator. At the heavy course of malaria with massive hemolysis and a coagulopathy shock, ischemic necroses of a canalicular epithelium quite often develop that leads to an acute renal failure and an anury. Clinically at the same time jaundice, a gepatosplenomegaliya, a hemorrhagic syndrome, anemia, a sopor or a coma are observed. In case of a long anury and uraemia there is a need for use of a hemodialysis. Other complication of malaria is the glomerulonephritis, an origin to-rogo connect with the plazmodiyny antigen and a response immune response of an organism circulating in blood. Changes happen in renal balls — a thickening of a basal membrane and an endothelium of capillaries to adjournment on a membrane and in a mezangiya of deposits. These changes, as well as the proteinuria which is observed at them, disappear at treatment of malaria and removal from blood of antigen. The quartan malaria often becomes complicated hron, the progressing glomerulonephritis which in the subsequent leads to a total sclerosis of renal balls and an atrophy of renal tubules. At the beginning of a disease the nephrotic syndrome is often noted, then hypostases disappear and there is arterial hypertension foretelling a renal failure. Antimalarial treatment does not improve a current of this form of a glomerulonephritis. Therapy by glucocorticoids gives remission only at a proteinuria of the selection type. See also Malaria .

Cholera — a serious infectious disease with preferential defeat went. - kish. path and bystry loss of a large amount of water and salts. The hypovolemic shock which is followed by changes of the tubulointerstitsialny device P is a consequence of an eksikoz. The oliguria developing in process of increase of dehydration is characterized by the high density of urine in the beginning; decrease in density of urine and developing after this an anury is pointed to deeper defeat of the Item. The prevention and treatment of a renal failure at cholera provide adequate compensation of loss of water and electrolytes. At an anury, unsoluble by means of conservative treatment, the hemodialysis is shown. See also Cholera .

A salmonellosis as heavy systemic infection quite often is followed by shock with damage of a liver and P. Zabolevaniye begins with fever and the expressed toxicosis, in the subsequent vomiting, a diarrhea, jaundice, increase in a liver and spleen, a renal failure, a hemorrhagic syndrome develop. Due to the long anury treatment is shown to patients by a hemodialysis. See also Salmonellosis .

Scarlet fever at the height of a disease is complicated sometimes by acute tubulo-intersticial nephrite (see). In the period of reconvalescence there can be an acute poststreptokok-kovy glomerulonephritis, for to-rogo rather favorable current and often absolute recovery is characteristic. See also Skarlatin.

The candidiasis of kidneys happens usually at generalization of process. Infection happens hematogenous, more rare in the ascending way. The disease proceeds in the form of a diffusion intersticial inflammation about a wedge, displays of pyelonephritis or as the miliary abscessing reminding on a wedge, a picture sepsis with pain in lumbar area and a gross hematuria. In the subsequent P.'s abscesses develop, ulcer and necrotic piye-loureterit, cystitis, there are a dysuria, disturbances of outflow of urine, renal colic, a renal failure. On a wedge, to a current and rentgenol. it is difficult for signs to distinguish a disease from P.'s tuberculosis, purulent pyelonephritis therefore for diagnosis detection of fungi in blood and urine matters. At treatment of candidiasis of P. use antifungal drugs in a combination with the antibiotics which are not possessing mycogenic action (gentamycin, erythromycin), streptocides of the prolonged action. Also Amphotericinum is shown In, but this antibiotic differs in high nephrotoxicity. See also Candidiasis.

At an actinomycosis (see) P.'s infection happens in hematogenous, seldom contact way. In the struck body there are small centers of suppuration, from to-rykh the large abscesses differing in sluggish inflammatory reaction and tendency to formation of long not healing fistulas form. Because of the expressed perifocal infiltration there is a deformation and a sklerozirovaniye of body. Pararenal cellulose and uric ways are involved in process. Klien, a picture is a little characteristic: the chronic, exhausting septic disease is supplemented with a back pain, a hamaturia, a leukocyturia, a dysuria, renal colic. In case of a paranephritis symptoms of local suppuration join. Presurgical diagnosis of an actinomycosis of P. is difficult. The disease has looking alike tuberculosis, echinococcosis, a tumor of the Item. The diagnosis is more probable at detection of druses an actinomyce in urine or by means of a biopsy of a mucous membrane of a bladder. One of complications of an actinomycosis is the amyloidosis of the Item. Treatment of an actinomycosis of P. operational. After a course of antibacterial therapy and hemotransfusions under the general anesthesia delete P., an ureter and the cellulose surrounding them, warning thereby a palindromia.

P.'s tuberculosis develops at 4 — 5% of patients with primary and pulmonary localization of process. The hematogenous way of infection assumes bilateral defeat of the Item. Primary affect in the form of miliary tuberculomas (a focal necrotizing glomerulitis) is inclined to healing and petrification. However a part of granulomas breaks up, and the infection migrates on renal tubules in marrow P. where generally and process in the form of ulcer and cavernous defeat is developed. The bacteriuria promotes contact infection of uric ways. Ulcer and necrotic process, beginning with renal cups and a pelvis, extends on uric ways, affects a prostate gland, an epididymis and a deferent duct. In an end-stage nefro-cirrhosis, omelotvorenny P., a pyonephrosis, a secondary amyloidosis, a renal failure develop. After treatment of tuberculosis of P. in it the nephrosclerosis expressed in various degree is found.

A wedge, manifestations at P.'s tuberculosis vary depending on a stage of process. Quite often the disease begins with a leukocyturia, a bacteriuria, sometimes the first symptom is the gross hematuria. Widespread process proceeds with symptoms of cystitis and epididymite. Fever, perspiration, weight loss are expressed not always. The weight or dull ache in a waist alternating with renal colic appear later. A reason for inspection and diagnosis of tuberculosis of P. men can have an infertility.

Diagnosis of tuberculosis of P. is based on data fizikalyyugo researches, detection of mycobacteria of tuberculosis in urine, tsistoskopi-chesknkh signs of defeat of the mouth of an ureter and a bladder (tubercular hillocks, specific ulcers), rentgenol, signs (cavities, petrifikata, destruction of renal nipples, deformation of uric ways, etc.). Survey X-ray analysis at tuberculosis of G1. in 5 — 10% of cases reveals kroshkovidny, speckled structures, irregular shape of calcification of a parenchyma out of pyelocaliceal system. At excretory, especially infusional, Urografinum is defined not only the most characteristic symptom of tuberculosis — a cavity, but also initial changes — a specific papillitis. At it the arches of small renal cups uneven, corroded, and at destruction of a renal nipple a contrast agent gets out of limits of a cup into fabric of a nipple or a renal pyramid. Deformations of necks, narrowing of small renal cups at the expense of specific infiltrate with formation of a hydrocalycosis, amputation of cups can come to light. Resort to a retrograde piyelografiya only in cases of falloff of function II. Additional data on the extent of process and extent of destruction of a parenchyma receive by means of an angiography.

Treatment complex. It includes purpose of tuberculostatic, antisclerous, fortifying means, a dignity. - hens. and operational treatment. The purpose of operational treatment is correction of disturbances of urodynamic, removal of the center of an infection at preservation of body, removal is irreversible the struck body. The forecast is defined by a stage and prevalence of process, development of an amyloidosis and a renal failure. See also Tuberculosis extra pulmonary, tuberculosis of urinogenital bodies.

At the secondary acquired syphilis and the glomerulonephritis of the immu-nokompleksny nature induced by antigen of a pale treponema occurs at children of the first half of the year of life with inborn syphilis. In renal balls diffusion changes, intensity prevail to-rykh varies. The main type of changes consider moderate mezangialny proliferation with subepytelialny and mezan-gialny deposits, epithelial proliferation meets formation of typical semilunums. More than in 1/3 cases mononuclear infiltration of intersticial fabric is observed. The main display of a disease consider a nephrotic syndrome, the isolated proteinuria meets. Antibacterial treatment leads to remission. A recurrence of a disease is possible. At tertiary syphilis gummous defeats of the Item meet. Gummas (single, multiple and miliary) lead to development of symptoms of krui-noochagovy, melkoochagovy or diffusion defeat of the Item. Regarding cases vascular defeats of P. in the form of an endarteritis and arterial hypertension prevail. Occasionally the generalized vasculitis meets a renal failure. The secondary amyloidosis of P. See also Syphilis is possible.

The leprosy is followed by development of three types of renal complications.

1. The glomerulonephritis with polymorphic changes of renal balls and various a wedge, manifestations, among to-rykh prevails a syndrome of an acute glomerulonephritis. The immunocomplex nature of a glomerulonephritis, but as a starting factor, except leprose antigen is established, the role of antigens of the infection which is associated with a leprosy is studied (staphylococcus, etc.). 2. The defect of tubules of distal department of nephron with the lowered P.'s ability to an atsidifikation and concoction of urine caused by tubulointerstitsialny damage. 3. The secondary amyloidosis of P. develops preferential at lepromatous and boundary forms of a leprosy; is one of the frequent reasons of uraemia and a lethal outcome at a leprosy. See also JIenpa.

The sarcoidosis is followed by renal complications in 5 — 22% of cases. The glomerulonephritis with a wide range morfol, changes (from hymenoid is known about subendothat-lialnymi deposits to a total sclerosis and a hyalinosis of renal balls) and a wedge, a picture of a nephrotic syndrome. The pathogeny of a glomerulonephritis is connected with formation of autoantibodies to subcellular (mitochondrial) structures that gives it looking alike a pathogeny of lupoid nephrite. For a sarcoidosis typically granulematozny defeat of P. which is shown symptoms of bilateral, many and focal process and a renal failure. Due to the hypersensitivity to vitamin D at a sarcoidosis the hypercalcemia (see), a consequence a cut takes place can be a nephrocalcinosis (see) and a nephrolithiasis (see the Nephrolithiasis). Apply glucocorticoids to treatment of renal complications of a sarcoidosis. See also With an arch of doses.

Parasitic diseases

the Echinococcosis of kidneys is caused by a larva of tape Echinococcus granulosus helminth. P.'s defeat makes, according to various data, 0,2 — 5,4% of total number of an echinococcosis of various localizations. Gidatida is brought in P. usually by current of an arterial blood and develops preferential in cortical substance with the subsequent germination in renal cups, a pelvis or the fibrous capsule. The left P. is surprised more often; cysts develop usually on a front surface of P., in its lower segment. The invasion occurs usually in the childhood, but because of slow growth the cyst comes to light more often at the age of 20 — 50 years. Endogenous growth of a cyst happens due to formation of affiliated bubbles and stretching of walls under the influence of intravesical pressure. Exogenous growth — result of protrusion of a scolex from a germinal layer outside to surrounding fabrics. Growth of a cyst is interfered by resistance of the fibrous capsule and surrounding fabrics and their insufficient blood supply.

Distinguish the closed cyst with the unimpaired wall (tsvetn. fig. A. 6), the pseudo-closed cyst, prolabiruyushchy in a renal cup and washed by urine, the open cyst which is reported with pyelocaliceal system, the ekhinokokkuriya, implantation of affiliated bubbles in one of renal cups, an empyema of cyst, P.'s inflammation and an ureter can be a consequence of what.

Depending on size and an arrangement of an echinococcal cyst there is P.'s removal, deformation and expansion of renal cups and a pelvis, an atrophy of a renal parenkhikhma. In process of growth of an echinococcal bubble the most part or all renal fabric is exposed to an atrophy.

A wedge, displays of echinococcosis of P. depend on an arrangement and the size of an echinococcal cyst, character patol, changes in P., existence of complications, and also toxic action of a parasite on an organism.

During a disease distinguish stage of latency from the moment of implementation of a parasite to the first a wedge, manifestations. It usually has big duration that is explained by the slow growth of an echinococcal cyst and the fact that its fibrous capsule interferes with penetration into an organism of products of metabolism of helminth. During this period the parasite can die and undergo further calcification. In the same time symptoms of intoxication, an easy indisposition, bystry fatigue, weakness, a loss of appetite, a weight loss can be noted.

During the period a wedge, displays of a disease the most frequent symptoms are slowly growing tumorous education in hypochondrium, dull constant ache in hypochondrium or lumbar area, renal colic. Pain can irradiate to the subclavial area and a shovel, the lower extremity. Otkhozhdeniye with urine of affiliated echinococcal bubbles usually is followed by renal colic, a hamaturia, and sometimes an exacerbation of pyelonephritis, a dysuria, an ischuria, at break of the suppurated cyst — a leukocyturia. Due to emptying of a cyst increased in sizes P. by some period decreases, however recovery does not occur. Subfebrile or febrile temperature is noted that it is connected with infiltration of the infected gidatidny liquid in tissue of a kidney. The allergic phenomena in the form of a skin itch, an eosinophilia are occasionally observed.

The diagnosis of a disease, except for cases with an ekhinokokkuriya, is difficult and can be established as a result of comprehensive examination. Data on a profession of the patient, residence in districts of spread of helminthosis, on contact with domestic animals matter. At thin patients in the presence of large cysts deformation of a stomach is defined. Cysts of the lower pole of P. are palpated in the form of roundish tumorous educations in hypochondrium. At the expense of an inflammation and a spayaniye with surrounding fabrics P. Palpation's mobility is broken happens painful in case of accession of inflammatory process. The surface of a cyst smooth or hilly, a consistence its dense, is more rare elastic. Pasternatsky's symptom (see Pasternatsky a symptom) happens positive at accession of inflammatory process or disturbance of outflow from earlier opened cyst.

Changes of urine at the closed form of an echinococcosis of P., according to E. G. Aslamazov, are characterized in 19% of cases by a leukocyturia, in 11,9% of cases — a hamaturia, sometimes — an ekhinokokkuriya. At an open form the pyuria is observed in 60%, a hamaturia — in 20% of cases. Urine muddy, contains flakes, scraps of nekrotizirovanny fabric. Toxic action of an echinococcus on P. in 7,7% is shown by a proteinuria, a cylindruria. In blood at 20% of patients the moderate eosinophilia, in 28% — a moderate leukocytosis, at 65% — the accelerated ROE is noted. Reaction has great diagnostic value latex agglutination (see Agglutination), edges is carried out with an echinococcal diagnosticum and at the died echinococcus happens negative.

At a tsistoskopiya the nonspecific changes of a mucous membrane of a bladder and the mouth of an ureter on the party of defeat sometimes born or freely floating whole or burst affiliated bubbles can be found. By means of a survey X-ray analysis of uric ways to 10% of cases the contour of the increased P., in 25 — 30% — its calcification in the form of gentle hardly noticeable line or accurate ring-shaped education comes to light. At death and calcification of affiliated bubbles the cyst comes to light in the form of homogeneous or plumose roundish education. Excretory urography (see) reveals changes of the pyelocaliceal system struck with P. Piyelograficheskiye data depend on relationship of a cyst with pyelocaliceal system. At the closed cyst which is localized in an upper pole of P., the renal pelvis and cups are pushed aside from top to bottom and to the centerline; at localization in the lower pole renal cups are pushed aside up, the ureter is displaced medially, its gleam is squeezed; at an arrangement in a middle part of P. the renal pelvis gets a form of a half moon. At an open cyst continuous or discontinuous communication between a maternal bubble and pyelocaliceal system is established. On a piyelogramma along with the image of the deformed renal pelvis the cavity of a cyst is contrasted. Affiliated bubbles in a pelvis give gentle roundish shadows like bee cells or a bunch. At occlusion of an ureter affiliated bubbles the picture of a hydronephrosis comes to light.

Ultrasonic scanning (see. Ultrasonic diagnosis ) is of great value in recognition of an echinococcal cyst, allows to define the additional ekhostruk-tours caused by the dead and the wrinkled affiliated echinococcal bubbles, and also tumoral growths at a malignancy of an echinococcal cyst. By means of an angiography at P.'s echinococcosis avascular education — the defect of filling in a zone of a cyst indicating a tumor or a malignancy of a solitary cyst («defect in defect») comes to light; at P.'s echinococcosis it can be caused by projection of the condensed affiliated echinococcal bubbles. Scanning of kidneys and a dynamic stsintigrafiya allow to reveal localization, volume and extent of destruction of body.

The differential diagnosis of an echinococcosis of P. is carried out with a tumor, a solitary cyst, a hydronephrosis (tsvetn. fig. A. 4), nephrolithiasis. Before operation the topical diagnosis since defeat of a nechena, a spleen, distribution to retroperitoneal space is possible is obligatory.

Treatment — operational. Its purpose — to remove a parasitic cyst and as much as possible to keep the functioning renal fabric. The nature of intervention P.'s condition, its vascular very tectonics, topographical relationship with the next bodies and fabrics, a state determine functional and morfol, another by P. Provodyat an ekhinokokkoto-miya, an ekhinokokkektomiya (see. Echinococcosis ), P.'s resection, nephrectomy (see).

The forecast depends on expressiveness of intoxication of an organism; at an empyema of cyst with development of a septic state and a rupture of an echinococcal bubble with planting of cavities and fabrics the forecast worsens.

An alveococcosis of kidneys — heavy hron, the disease caused by a larval stage of Echinococcus alveolaris (multilocularis) with formation of the centers of a productive and necrotic inflammation. While at an echinococcosis there is one large cyst with the expressed cover and affiliated bubbles in it, at an alveococcosis (see) the maternal cyst is absent; there is a proliferation without formation of macroscopically visible cysts. Consistence alveokokkozno-go node dense, almost cartilaginous; the node of grayish-white color, macroscopically reminds a malignant tumor. It consists of neogenic connecting fabric, in a cut the numerous small fallen-down bubbles of a parasite are located. Quite often fabric in a node breaks up with formation of the cavity filled with putreform brown liquid, limy inclusions, a scolex and other elements of a parasite.

P.'s alveococcosis meets extremely seldom. In all cases of detection primary center was in a liver, and P. was involved in process for the second time due to infiltrative growth on interfabric cracks.

The diagnosis is difficult. It is almost impossible to Otdifferentsirovat P.'s Echinococcosis from an alveococcosis since P.'s increase, density, calcification, an eosinophilia, positive reaction latex agglutination can take place at both diseases. The hamaturia, the palpated education allow to suspect a new growth of the Item of renal area. At rentgenol, a research find not clearly outlined shadow, sometimes sites of plumose calcification in P.'s projection; on excretory Urogramums and a retrograde piyelogramma — a pushing off of renal cups and a pelvis, their deformation; at considerable defeat of P. on Urogramum there is no release of contrast medium.

Treatment — operational. It shall be carried out before infiltration of the next bodies and fabrics and development of metastasises. Considering the secondary nature of defeat of P., it to a certain extent can be considered palliative.

The forecast of a disease is serious, life expectancy can make several years. Usually patients perish from a liver failure (see) or cachexias (see), is more rare from metastasises of an alveokokk in a brain.

Damage of kidneys at filariases. Infection occurs at a sting nek-ry species of mosquitoes — carriers of larvae of a parasite (microfilarias). Is surprised limf, system, in a cut limfangiita, thrombosis limf, vessels and a lymphostasis with expansion collateral limf, vessels, a hyperplasia and a sclerosis limf, vessels are observed. In process of increase in hydrostatic pressure varicose limf, vessels are broken off and the lymph streams in uric ways, being added to urine. The anastomosis between lymphatic and uric systems forms more often at the level of a renal nipple or taking away limf, vessels 3 — the 4th order. Clinically this state is characterized chyluria (cm.), and at an additional rupture of blood vessels — a gematokhiluriya, release of urine of lactescence (galacturia). The chyluria can be a constant or periodically arise. Its emergence or strengthening can be provoked by reception of plentiful greasy food, an exercise stress, pregnancy, disturbance of a passage of urine. Proceeding for years, the chyluria can not cause any painful feelings, and patients keep working capacity though they are usually disturbed by the fact of release of urine of lactescence. Most of patients feels the weight in lumbar area, a thicket on the party of defeat which is replaced by attacks of renal colic. Perhaps complicated urination and even an ischuria. The chyluria is often combined with hron, cystitis and pyelonephritis. Urine at a chyluria has whitish color at the expense of the emulsified neutral fats, the quantity to-rykh depends on their contents in food. Fat is defined in urine macroscopically or in the form of the smallest drops under a microscope. At accession of a hamaturia urine gains cream or brown color. Except fat, erythrocytes and leukocytes urine contains protein and fibrinogen what formation of clots is connected with. These clots break outflow of urine from a renal pelvis, cause pains of the aching character in lumbar area or renal colic; in the presence of clots in a bladder the complicated urination or an ischuria is noted. Urine at a chyluria, being upheld in the glass cylinder, forms three layers: upper contains fat, average — fibrinogen, albumine and globulins, lower — erythrocytes and leukocytes. The quantitative and qualitative composition of fat and protein in urine is identical to their structure in blood serum. Continuous losses of fat and a squirrel bring to dis-and hypoproteinemias, to considerable exhaustion of the patient.

The diagnosis of a chyluria is established on the basis of detection in urine of fat and protein, the parasitic nature of a disease — during the finding of microfilarias. Lympho-urinarnogo an anastomosis makes a direct limfangioadenografiya for identification (see Limfografiya). It gives the chance to determine the extent of process in limf, system.

Apply to treatment on citrate, carry out local impact on a limfourinarny anastomosis of 1 — 2% by solution of silver nitrate or operational destruction limf, P.'s bonds with the main limf, collectors. The forecast at timely treatment favorable.

Shistosokhmatoz of kidneys meets extremely seldom and there are single observations of a direct injury of P. Obychno P. is involved in process for the second time in connection with obstruction of intramural department of an ureter due to adjournment of Schistosoma haematobium eggs and development of productive and sclerous process in its wall that leads to a hydronephrosis and hron, to pyelonephritis.

The aching pains in lumbar area, attacks of acute pains on the party of defeat, quite often symptoms of pyelonephritis are clinically noted. The long time process can proceed asymptomatically. In most cases the hydronephrosis of different degree develops.

The diagnosis establish on the basis of an obraruzheniye of eggs of a parasite in urine, typical changes on excretory Urogramums — a kolbovidny megaloureter over a stricture of terminal department, a hydronephrosis.

Treatment — operational after the previous therapy by antishistosomotsidny means. Considering the bilateral nature of defeat, it is necessary to aim at preservation of body. Generally perform the plastic surgeries on the lower third of an ureter directed to recovery of a passage of urine. At the expressed gidroureteronefroz the nephrectomy is shown.

The forecast depends on prescription of a disease and expressiveness of sclerous changes in P. See also Shistosomatoza.

The ascaridosis of kidneys meets seldom and can be connected with migration of larvae on circulatory system. Penetration of larvae and mature ascarids into pararenal cellulose and P. at perforation of a wall of a gut is more probable. Influence of helminthosis on P. can be shown by dystrophic changes of an epithelium of renal tubules that can clinically be shown by an uric syndrome. See also Ascaridosis .

A trichinosis of kidneys is a little studied. The invasion is followed by an albuminuria and an erythrocyturia of different degree. By means of P.'s biopsy reveal a mezangialny proliferative glomerulonephritis. Development of secondary pyelonephritis at implementation of trichinellas in muscles of bodies of uric system is possible. See also Trichinosis.

Metabolic a nephropathy

Metabolic a nephropathy — numerous hereditary diseases, at to-rykh P.'s defeat develops for the second time, owing to, disbolism. Carry to them angiokeratoz Fabri, oxa-rods, primary hyper uraturia, a cystinosis, glycogenoses.

Angiokeratoz Fabri — the rare disease which is genetically connected with X-chromosome, inherited retsessivno (see. Fabri disease ). Ceramide-trigeksoksidazy is characterized by disturbance in fermental system, disturbance of lipid metabolism — accumulation in walls of vessels of trigeksil-ceramide is a consequence of what. It leads to development of superficial ectasia of vessels with circulator frustration. In a wedge, allocate to a picture the periods of skin rashes, peripheral vasculomotor frustration and damage of internals. The first symptoms of a disease appear at children's age, and full a wedge, the picture is developed aged 15 years are more senior. Symptomatic treatment. Concerning a renal failure can be shown a hemodialysis (see) and renal transplantation (see). The outcome of a disease is defined by damage of heart and kidneys.

Oxarods, or primary hyperoxaluria — genetically caused disease which is followed by disturbance of exchange glyoxylic to - you (see Oksaloz). Formed at the same time a lot of oxalic to - that is postponed in the form of crystals in internals and P. Gistologicheski in P. comes to light a picture of a nephrocalcinosis with proliferation and a sclerosis of a mesangium of renal balls, crystals of calcium oxalate in renal tubules and intersticial fabric. Rather quickly the renal failure develops, at treatment a cut P.'s transplantation is not perspective.

Primary hyper uraturia — the inherited disorder of purine exchange which is transmitted on a dominant character and followed by excess accumulation and removal uric to - you and its salts (urates) with development of a picture of intersticial nephrite. Often at the same time the nephrolithiasis comes to light. Morphologically fibrosis of hl comes to light. obr. marrow P., adjournment of urates in the field of renal nipples. Clinically the disease is shown by a crystalluria, tubulointerstitsial-ache insufficiency, in analyses of urine find moderated to a protein I fly also a hamaturia; an important diagnostic character is detection in an uric deposit of crystals uric to - you. In late stages of a disease arterial hypertension, pyelonephritis and a renal failure which define further its wedge, a picture and an outcome joins.

Treatment consists in purpose of the diet excluding the products rich with purines and drink providing subacidic reaction of urine and a sufficient diuresis. During the progressing of a disease appoint Allopyrinolum and a complex to lay down. the actions directed to treatment of pyelonephritis.

Cystinosis — the caused disorder of exchange of cystine which is followed by its adjournment in internals and P. as a result is hereditary to-rogo the heavy nephropathy with a secondary tubulointerstitsialny syndrome and picture vitamin-B-rezistent-nogo of rickets develops (see the Cystinosis).

Disturbances of exchange of tryptophane often are followed by increase in excretion and its adjournment in internals. They can wear a uniform of syndromes of Hartnup and Tada. Hartnup's syndrome (see Hartnup a disease) is connected with disturbance of transport of tryptophane in intestines and proximal department of nephron that leads to development of a pellagropodobny dermatosis, attacks of a cerebellar ataxy, hyper aminoaciduria and increase in allocation of indole connections. Tada's syndrome is caused by deficit of a triptofaniirrolaza and is characterized clinically by defeat of a nervous system with frequent accession of pyelonephritis.

Glycogenoses — group of the hereditary enzymopathies arising in connection with deficit of enzymes, catalyzing processes of disintegration or synthesis of a glycogen, and which are characterized by its excess accumulation in various bodies and fabrics, including and in P. (see Glycogenoses). At the same time can be a lactacidemia (see) and a nephrogenic osteopathy (see the Osteopathy nephrogenic).

Secondary a nephropathy owing to electrolytic disturbances develop in connection with sharp shifts in metabolism of sodium, potassium, calcium, lithium and magnesium. The changes connected with disturbance of exchange of sodium are most studied.

Hyponatremia (see) exerts impact on P. owing to decrease in osmotic pressure of plasma and disturbance of blood circulation with decrease in glomerular filtering. The Hyponatremia from cultivation which is a consequence of the expressed hypostases or excess release of antidiuretic hormone meets more often. At a hyponatremia osmolarity of blood decreases that leads to defeat of tubules of P. owing to their overhydratation. Renal balls at the same time suffer for the second time since the gleam of tubules decreases. As a result glomerular filtering falls and there comes the azotemia (see). Treatment comes down to administration of hypertensive solutions of sodium chloride and Mannitolum. It is contraindicated to use hypertensive solutions of glucose since it is quickly metabolized in an organism that is followed by a fluid influx in a blood channel and eventually strengthens a gipoosmo-lyarnost.

Decrease in the general content of sodium in an organism is observed at plentiful vomiting, ponosa, is more rare at a so-called solteryayushchy kidney (inborn tubulopatiya, pyelonephritis, overdose of diuretics) that is followed by heavy dehydration (see. Dehydration of an organism ). However owing to loss of large amounts of liquid concentration of sodium in blood serum remains normal or increases. At the same time the volume of the circulating blood is always reduced. The pachemia leads to disturbance of microcirculation, decrease in glomerular filtering, and in hard cases — to development of an azotemia. Due to cellular dehydration the catabolism of proteins raises that along with reduced glomerular filtering leads to increase of an azotemia. Good to lay down. the effect is reached by use of isotonic solution of sodium chloride; injection of hypertensive solutions is contraindicated.

The hypernatremia seldom meets in a wedge, to practice and usually is result of excess administration of sodium. Occasionally it is observed at the gastroenteritis which is followed by a big fluid loss and also at nek-ry diseases of the central nervous system. At the same time hyper osmolarity and as its investigation — cellular dehydration develops. Therefore at patients thirst is noted, the diuresis can decrease and raise the content in blood of nitrogenous slags. Treatment comes down to introduction of large numbers (to 4 — 5 l a day) liquids.

Hypopotassemia (see) accompanies massive fluid losses at vomiting, a diarrhea, etc. it is combined with loss of sodium. Actually the hypopotassemia is observed at diseases of the kidneys which are followed by defeat of distal department of nephron (pyelonephritis, a tuba-lopatiya, a diabetes mellitus). The expressed hypopotassemia meets at primary aldosteronism. The lack of potassium promotes disturbance of osmotic concoction whereas ability to cultivation remains. Also intracellular acidosis develops. Similar changes are noted also in renal tubules that leads to the strengthened removal to - t. As a result a peculiar symptom complex — a combination of intracellular acidosis and an extracellular alkalosis develops.

Disturbance of concentration ability of P. at a hypopotassemia is originally connected with functional changes and disturbance of a reabsorption of sodium in the thick ascending part of a nephronic loop. Further the organic disturbances which are shown heavy changes of a distroficheskikhma in tubules and a sclerosis an interstitium develop. As a result of P. lose ability to creation of an osmotic gradient and concoction of urine. The developing gipokaliyemi-chesky nephropathy leads to the fact that P. become open to injury for an infection. The acute hypopotassemia is followed by decrease in a tone of smooth muscles with hypotonia, paresis of intestines, heart failure, an oliguria, an azotemia. Treatment comes down to recovery in an organism of reserves of potassium. For this purpose enter the products rich with potassium (nuts, dates, a beef-infusion broth, carrots, peas) into a diet of patients. In hard cases resort to intravenous administration of solutions of potassium or mix of solutions of potassium, sodium and glucose.

The hyperpotassemia is usually connected with acute and hron, a renal failure, and also an addisonovy disease (see). Euphoria, myofibrillar twitchings, changes of an ECG are clinically noted. At substantial increase of content of potassium use of a hemodialysis or kationitny sorbents is shown.

Disturbances of exchange of calcium are followed by P.'s changes. The hypocalcemia usually is a consequence hron, a renal failure, as a result the cut is broken metabolism of vitamin D and absorption of calcium in intestines; the hyperparathyreosis arising for the second time is followed by the strengthened washing away of calcium from bones and its removal through P. Giperkaltsiyemiya develops owing to exchange disturbances or tumoral process. Manifestations from P. originally have character of dystrophic changes of an epithelium of tubules of distal department of nephron. Quickly enough after this the centers of a necrosis and obstruction of renal tubules appear, in to-rykh there is an adjournment of calcium. Further proximal departments of nephron and renal balls are involved in process. At the expressed nefro-kaljtsinoz (see) the interstitium is surprised.

At early stages of process establish decrease in the concentrating ability P. Mekhanizm of this phenomenon is difficult and at early stages is connected with decrease in sensitivity of collective renal tubules to antidiuretic hormone. The formed complex of calcium with ATP reduces transport of sodium in the thick ascending knee of a nephronic loop that leads to alignment of an osmotic gradient between an interstitium and a vnutrika-naltsevoyzhidkost. In a stage of organic changes calcification of renal tubules and an interstitium is followed by disturbance of activity of counter-current rotary multiplying flow system. Release of urine of low osmotic density is as a result characteristic. Clinically it reminds not diabetes mellitus, but not sensitive to Pituitrinum.

Disturbances of metabolism of magnesium exert insignificant impact on activity of the Item. Hypomagnesiemia develops under the influence of the various reasons (a hyper aldosteronism, a hypercalcemia, poisoning with gentamycin, hron, alcoholism). Klien, P. given about influence of this state on activity are absent. The strengthened adjournment of calcium in tubules of proximal departments of nephrons is experimentally revealed.

Gipermagniyemiya comes to light at hron, a renal failure. It is established that ions of magnesium reduce a reabsorption of sodium in proximal departments of nephron and partially in a nephronic loop. There are data on reduction of a renal blood-groove under the influence of salts of magnesium.

Lithium clearly affects function P. It is easily filtered in renal balls and reabsorbirutsya in tubules of proximal departments of nephron. At prolonged use of lities the hl collects in renal fabric. obr. in marrow. At the same time electronic microscopically find expansion of tanks of a cytoplasmic reticulum and hypostasis of mitochondrions. Changes in distal departments of nephron, and also a fornikalny sclerosis are observed. At the same time thirst and a polyuria is noted. The mechanism of this phenomenon is connected with disturbance of a reabsorption of water and P.'s inability to concentrate urine. Believe that lithium brakes adenylatecyclases-nuyu system of collective renal tubules therefore sensitivity to effect of antidiuretic hormone decreases. Also primary impact of lithium on a hypothalamus is not excluded that leads to emergence of thirst and a polyuria. Under the influence of lithium removal of sodium and potassium from an organism amplifies, sensitivity of cells of distal department of nephron to Aldosteronum as a result decreases. There are data that Aminophyllinum and Mannitolum strengthen removal of lithium from an organism.

Medicinal defeats

At reception of pharmaceuticals can develop medicinal nephrite or the toxic nephropathy connected with effect of drugs or the metabolites which are formed at their disintegration, perhaps combined defeat.

Medicinal nephrite of an immune origin can develop at reception of any pharmaceuticals. At reaction of immediate type P.'s defeat comes to light against the background of an acute anaphylaxis (see), at reaction of the slowed-down type it is combined with other manifestations of side effect of drugs. In renal fabric at the same time immune complex depositions appear. Toxic impact on P. occurs owing to bystry strengthening of substances. Pharmaceuticals can be filtered in renal balls, but then reabsorptions in renal tubules are exposed that leads to penetration them in intersticial fabric. Antibiotics of aminoglikozidny group, nephrotoxicity possess the direct damaging action to-rykh decreases in the following order — Neomycinum, Monomycinum, Kanamycinum, streptomycin. Possess a certain nephrotoxic action also Amphotericinum In, polymyxin B, florimitsin and gentamycin. Drugs of a tetracycline row have toxic effect on P. at their overdose. Sodium salicylate and Butadionum break processes of oxidizing phosphorylation in cells of renal tubules and at long use can cause development of a toxic nephropathy.

The problem of the mechanism of development of a medicinal nephropathy is studied insufficiently. Carry penicillin, streptocides, cytostatics, some antitubercular (Tubazidum) and anticonvulsants (Trimethinum), drugs of gold, nitrofurans to number of the pharmaceuticals leading to development of such defeat of P. and thiazide diuretic, etc.

Morfol, changes in P. are various. At diseases of immune genesis preferential defeat of renal balls, changes in an interstitium and vessels comes to light. It is also various gistol, the picture at toxic nefropatiya, for to-rykh is characteristic dystrophy of cells of an epithelium of tubules, changes of renal balls and an interstitium are frequent, in to-rykh infiltration by lymphocytes and plasmocytes comes to light. Elektronnomikroskopicheski is marked out adhesion of podocytes and a thickening of a basal membrane. At a medicinal nephropathy defeat of an interstitium of marrow P comes to light.

Temperature increase, skin rashes are clinically noted, arthralgias are often observed. In hard cases development of a Lyell's disease is possible (see. Necrolysis epidermal toxic ) and agranulocytosis (see). Terms of defeat of P. are various — from the first days to several months from the beginning of reception of medicine. At the same time the ABP raises, hypostases develop, at a research of urine the proteinuria and an erythrocyturia are found. Occasionally the nephrotic syndrome develops. In blood the eosinophilia is noted, the hypergammaglobulinemia and a ginerfib-rinogenemiya biochemical come to light. In rare instances P.'s defeat is shown by an acute renal failure. Occasionally the nephropathy proceeds asymptomatically and changes come to light only in analyses of urine. Patients note thirst and a polyuria. Therapy comes down to respect for the following principles: 1) cancellation and removal from an organism of medicine; 2) appointment hyposensibilizing and antihistamines; 3) a symptomatic treatment of the arisen complications. The result of medicinal defeat of P. depends on expressiveness morfol, changes. In case of acute defeat with development of an acute renal failure or at anaphylactic reaction of immediate type the forecast can be adverse. In other cases there comes the absolute recovery.

The leukoplakia of a renal pelvis — seldom found disease, a cut is expressed in emergence on a mucous membrane of a pelvis of silver-white or nacreous plaques of various sizes and forms with accurately outlined edges. Quite often they merge, sometimes pass to a mucous membrane of an ureter. The mucous membrane of a renal pelvis becomes dry and rough, after removal of a plaque — bleeds. Development of a leukoplakia (see) connect with hron, an inflammation of a renal pelvis, and also individual properties of an urothelium. The view of a leukoplakia as a pretumor condition of a mucous membrane of a renal pelvis is disputed by many scientists.

At microscopic examination the metaplasia of a transitional epithelium of a mucous membrane in multilayer flat with keratinization of surface layers comes to light. The subject layers of a wall of a pelvis of an infiltrirovana leukocytes and limfogis-thiocytic elements.

The wedge, a picture is characterized by drift, emergence of the symptoms similar to symptoms hron, pyelonephritis (pain in lumbar area, a dysuria, a microhematuria, a leukocyturia). Sometimes there is a gross hematuria connected with rejection of plaques and formation of ulcers and cracks on a mucous membrane. At occlusion of an ureter renal colic arises the torn-away layers of a keratosic epithelium, acute pyelonephritis can develop.

Diagnosis is difficult. Recognition of a disease is helped by detection with an urocheras of cells of a keratosic epithelium, the torn-away small scales or layers in the form of the curtailed nacreous tubes. On a piyelogramma so-called lamination of a renal pelvis comes to light, defects of filling are found. During the involvement in process of an ureter it also gains lamination and a chetkoobrazny form on an ureteropiyelogramma. The differential diagnosis is carried out with a papillary tumor of a pelvis.

Conservative treatment is ineffective. Operation of the choice is the nephroureterectomy. Forecast adverse.

Displacing lipomatoz — growth of fatty tissue in retroperitoneal space around P. V process also next bodies and fabrics are involved. Clinically the disease is shown by pains, existence of tumorous education, dyspepsia. The diagnosis is established by means of the excretory urography, a retrograde piyelografiya, a pneumoretroperitoneum revealing deformation of pyelocaliceal system and shift of the Item. The differential diagnosis is carried out with hydronephrosis (see), P.'s tumor, cyst ovary (see), a cyst of a pancreas (see), splenomegaly (see).

Treatment — operational, is directed to full removal of lipomatous masses; in case of germination of P. by them make a nephrectomy. A recurrence is frequent, the malignancy is possible.

Tumors

make P.'s New growths, according to various data, apprx. 2 — 3% of all new growths at adults and apprx. 25% of all tumors at children. Distinguish benign and malignant tumors of P., a tumor of a renal parenchyma, renal pelvis, and also secondary (metastatic) tumors.

Benign tumors

the Most frequent of benign tumors of P. are adenomas (see. Adenoma ). Most often find solitary adenoma of one of P., sometimes the multiple tumors which are located both in one and in both kidneys. The arrangement of adenomas in cortical substance (cortical adenomas) is typical. Usually they multiple, various sizes, yellow color on a section, are surrounded with the capsule.

Adenomas develop from an epithelium of renal tubules; their stroma usually consists of thin layers of nezhnovoloknisty connecting fabric with the insignificant number of thin-walled veins. On tsitol, to symptoms of adenoma of P. can be clear cell (hypernephroid), basphilic (dark-cell), eosinophilic (including onkotsitarny), granular cell and mixed. On the general gistol, structure distinguish the adenomas solid (trabecular), tubular, papillary, cystous (cystadenomas) mixed and also fibroadenomas. Clear cell adenomas are considered by many researchers as a stage of development of an adenocarcinoma

of P. Klinicheski large adenomas of a kidney can be shown by a hamaturia, pain, arterial hypertension and the education palpated in hypochondrium.

The lipoma meets seldom, is located in cortical substance P more often. Usually it is an odinochna, it is small, however in some cases reaches in dia. 10 cm and more. The tumor has a soft consistence, on a section fabric of its lobular structure, quite often with dystrophic changes. Histologically the tumor is constructed of mature fatty tissue (see the Lipoma), segments a cut are divided by connective tissue layers. P.'s lipoma needs to be distinguished from the fatty substitution which is observed at the nephrolithiasis complicated hron, pyelonephritis.

Fibroma (see Fibroma, a fibromatosis) is more often localized in marrow P. in the form of dense nodes of grayish-white color to dia. 1 — 2 cm. Single observations of huge fibromas weighing 9 and 17 kg are described. The tumor is constructed of collagenic fibers, fibrocytes and fibroblasts and contains the moderate number of veins. Only big fibromas available to a palpation are clinically shown. Sometimes they cause a hamaturia.

A leiomyoma (see) most often has an appearance of small dense small knots of gray-white or gray-pink color on a section. Histologically consists of bunches of mature smooth muscle cells. Sometimes the tumor reaches considerable and even huge sizes and then is shown clinically.

The hemangioma is observed seldom (see the Hemangioma). Usually is located in marrow P. or in a wall of a renal pelvis. At a hemangioma of cortical substance P. massive hemorrhages in paranefry are described.

The lymphangioma (see) has an appearance of small knots with a diameter from 0,2 — 0,3 cm before large educations with a chicken skin. On a section the tumor consists of a set of the anastomosing cavities of various form and the sizes filled with colorless transparent or rather turbid whitish liquid.

Seldom other tumors, napr, a neurofibroma (see), a ganglioneuroma (see), a pheochromocytoma (see), teratomas meet (see).

Papilloma of a renal pelvis develops from a mucous membrane of a pelvis, a cup or a lokhanochno-ureteric segment. The tumor of a soft consistence, can be the different size, with the short or long branching vorsina. Multiple papillomas in a pelvis, an ureter, a bladder are quite often observed (see Papilloma, a papillomatosis). In such cases the multi-tsentrichny growth of a tumor is supposed though some researchers do not exclude a possibility of implantation of tumor epithelial cells on the course of uric ways. Quite often at high-quality in morfol, the relation of a tumor clinically malignant current is observed.

The big rarity of benign tumors and a possibility of a malignancy nek-ry of them oblige to suspect a malignant tumor of each case of clinically shown P.'s tumor and to conduct the comprehensive examination including angiographic (see fig. 3 to St. Renal angiography) and ultrasonic methods, computer tomography. Though reliability of modern methods of a research is very big, doubtful these inspections in the presence a wedge, symptoms of a tumor dictate need of an operational exposure of P. and its audit, and in case of need and carrying out urgent gistol, researches. If on the basis of a gross appearance and data gistol, researches of a tumor its high-quality character is revealed, it is possible to be limited to enucleation of a tumor or a nephrectomy.


From the additional materials

K to rare benign organospetsifichesky tumors of kidneys carry an angiomyolipoma, a kongenitalny mesoblastic nephroma, a juxtaglomerular cell tumor and a tumor from intersticial cells of marrow.

P.'s angiomyolipoma is quite often combined with a tuberous sclerosis (see) and in this case meets at adults more often. Defeat can be multiple and bilateral. In the absence of a tuberous sclerosis the tumor is found only in adults, is more often at women, usually single, unilateral, is localized in one of poles P. Angiomiolipoma P. is constructed of blood vessels, smooth muscular and mature fatty fabrics. A wedge, manifestations at small tumors, as a rule, are absent. At large tumors pain and a hamaturia are most often noted (see). The diagnosis is usually established at gistol. research. Treatment at hemilesion operational — a nephrectomy (see). Forecast doubtful; sometimes there is a rupture of a tumor with massive bleeding, pyelonephritis joins (see). The lipoma does not recur Angiomio.

The Kongenitalny mesoblastic nephroma is described by R. P. Bolande and soavt. in 1967. Meets seldom, preferential newborns and children of the first months have lives. Defeat is usually unilateral. More often the tumor occupies more than a half of a kidney, has a dense consistence, on a section reminds a hysteromyoma, without the centers of a necrosis and hemorrhages, does not extend out of limits of a renal capsule. The tumor is constructed of the intertwining bunches of spindle-shaped (fibroblastopodobny) and smooth muscle cells and collagenic fibers, may support the single tubular structures covered by a cubic epithelium. The basic the wedge, a symptom of a disease is the education defined at a palpation in an abdominal cavity. The differential diagnosis carry out with Vilms's tumor (see Viljms a tumor). Treatment operational — a nephrectomy or a nephrectomy (see Kidneys, operations). Forecast favorable.

The juxtaglomerular cell tumor of a kidney is described by P. W. Robertson and soavt. in 1967 and irrespective of them I. Ki-hara and soavt. in 1968. Meets very seldom, preferential at young age, in the form of the small dense encapsulated node having brownish-yellow color on a section. It is constructed of small cells with puzyrkoobrazny kernels and slaboeozinofilny granular cytoplasm. Cells are derivatives of juxtaglomerular reninsekretiruyushchy cells of a kidney. Characteristic the wedge, manifestation is heavy diastolic hypertensia (see arterial hypertension). To assume existence of a juxtaglomerular cell tumor of a kidney as the reasons of this hypertensia sharp increase in activity of a plasma renin (see) in combination with a hypopotassemia (see) and the raised excretion of Aldosteronum allows (see). Localization of a tumor can be established by means of arteriography (see. Renal angiography). Treatment operational — a nephrectomy. Within the first days after operation ABP, Repin's activity and the maintenance of Aldosteronum in blood are normalized. The long-term results after operational treatment good.

The tumor from intersticial cells of marrow (estimated producers of renal prostaglandins) meets seldom. It represents roundish formation of belozhelty color in marrow with a diameter of 0,1 — 0,3 cm, sometimes to 1 cm, fibromatoid. It is microscopically constructed of the intersticial cells and separate tubular structures covered by a cubic epithelium. The tumor is studied insufficiently. Presumably it is carried to reactive educations or gamartoma (see). About a wedge, manifestations it is simple-glandinnoy activities of a tumor of the data are absent.

Bibliography: Vikhert A. M., etc.

To a question of angiolipoleyomioma of kidneys, Arkh. patol., t. 33, No. 12, page 21, 1971, bibliogr.; Golovin D. I. and P and y-to about in a JI. B. Angiomyolipomas of kidneys, Vopr. onkol., t. 26, No. 7, page 35, 1980;

Pathoanatomical diagnosis of tumors of the person, under the editorship of N. A. Krayev-sky, etc., page 191, M., 1982; Samsonov of V. A. Patomorfologiya of tumors of kidneys and upper urinary tract, M., 1981, bibliogr.; Conn J. W. and. lake of The syndrome of hypertension, hyperreni-nemia and secondary aldosteronism associated with renal juxtaglomerular cell tumor (primary reninism), J. Urol. (Baltimore), v. 109, p. 349, 1973;

S n y-d e r H. M. a. o. Congenital mesoblastic nephroma, ibid., v. 126, p. 513, 1981;

Wong A. L., Me George A. a. With lark A. H. Renal angiomyolipoma, Brit. J. Urol., v. 53, p. 406, 1981.

V. A. Samsonov.


Malignant tumors

Among malignant tumors of P. of St. 90% are made by an adenocarcinoma of clear cell type (see. Cancer ). Less often dark-cell, or granular cell and undifferentiated adenocarcinomas, sarcoma (see), a horionepitelioma meet (see. Trophoblastic disease ), Vilms's tumor (see. Vilmsa tumor ), cancer tumors of a renal pelvis, etc. In P. also metastasises of malignant tumors of other bodies can be found. More often in P. metastasizes cancer of a lung, also metastasises and other tumors meet.

Classification of malignant tumors by the TNM system is offered in 1973. International anticarcinogenic union. On this classification primary tumor is designated by a symbol T; Tkh — existence and prevalence of a tumor cannot be estimated (this category can be used at histologically or cytologic the confirmed metastasises in regional limf, nodes or the remote bodies); T0 — symptoms of primary tumor are absent (it can be applied the same as the previous category); Tg — the tumor is not palpated, but kliniko-rentgenol, data confirm its existence; T2 — a tumor is palpated, is well mobile, kliniko-rentgenol, and radio-gramophones, data confirm existence of a tumor; The T3 — a tumor is palpated, its mobility is limited, are available characteristic kliniko-rentgenol. symptoms; T4 — a tumor is palpated, is not mobile.

Regional limf, nodes (N): Nx — cannot estimate existence of metastasises; N0 — deformation regional limf, nodes, on a cut it would be possible to judge existence of metastasises, is absent; Nx — regional limf, nodes are deformed due to malignant process. The sign - + or — indicating on the infiltration revealed or not revealed histologically can be added to category N.

Remote metastasises (M): M0 — the remote metastasises are not defined; Mkh — the remote metastasises come to light; M1a — metastasises in limf, nodes; Mjb — metastasises in a bone; M1s — metastasises in internals; M1 (j — metastasises in lungs; M1e — biochemical signs of existence of the remote metastasises.

Gistol, criteria (R) — the distributional pattern of tumoral process defined at a research of a remote tumor: P0 — a pre-invasive carcinoma; Rkh — a tumor, infiltriruyushchy only P.'s parenchyma; P2 — a tumor infiltrirut the fibrous capsule P., a pelvis and (or) cups, without extending to surrounding bodies; P3 — a tumor sprouts pararenal cellulose; P4 — a tumor sprouts abdominal organs.

An invasion of veins — renal or lower hollow (V): Vx — information is absent; V0 — a vein is free; \1 — the vein is involved in tumoral process.

Histologic category (G): Oh — available information is absent; Gx — low degree of a zlokachestvennost; G2 — average degree of a zlokachestvennost; G3 — high degree of a zlokachestvennost.

Along with the given classification classification of the Phlox and Kadeski widely is used (R. The N of Flocks, Kadesky, 1959), on a cut distinguish: 1) a tumor within the renal capsule; 2) involvement in tumoral process of a vascular leg or pararenal cellulose; 3) involvement regional limf, nodes; 4) existence of the remote metastasises.

An adenocarcinoma (hypernephroid cancer, Gravit-ts's tumor, pochechnokletochny cancer, clear cell cancer) — a malignant tumor, coming from a renal epithelium. For the first time in 1883 Mr. P. Grawitz on the basis gistol, similarities of cells of a tumor to cells of cortical substance of an adrenal gland made a hypothesis of disturbance of a visceral embryogenesis, at Krom allegedly there is a drift of cells of an adrenal gland in fabric P. and development further from them a tumor. In 1930. A. I. Abrikosov spoke against this hypothesis and the assumption that this tumor arises from an epithelium of renal tubules.

It is more often observed at the age of 40 — 70 years, is almost twice more often at men, seldom perhaps bilateral defeat equally often strikes the right and left P. Krayne.

In an etiology of an adenocarcinoma of P. attach significance to an injury, hron, to inflammatory processes and other diseases of the Item. In some cases 20 — 30 years later after a retrograde piyelografiya by means of a thorotrast developing of a tumor of P., in particular adenocarcinomas was observed.

P.'s adenocarcinoma most often is located in cortical substance, has rounded shape, a soft consistence. The tumor is localized, as a rule, in one of poles of P. in the form of a node which can grow both vnutripochechno, and preferential ekstrarenalno. The tumor is usually encapsulated, on a section of a motley look — on a grayish-yellowish background the opaque centers of a necrosis, hemorrhage of various prescription, and also quite often cysts with yellowish or brownish liquid are disseminated (tsvetn. fig. A. 5). On section material in 1/4 — 1/3 cases germination of a tumor in surrounding fabrics and bodies, in 85 — 90% — metastasises comes to light (most often in lungs, limf, nodes, bones, a liver).

The basic gistol, a sign of a clear cell adenocarcinoma of P. is existence of polygonal or cubic cells (tsvetn. fig. A. 9) with nezhnoyacheisty light or «empty» cytoplasm (in connection with the maintenance in it of lipids and a glycogen). Rather small roundish kernel is located is central or is a little excentric. These cells creating an organospetsifichnost of a tumor form solid (trabecular), and also quite often ferruterous and papillary structures. The stroma is usually made by thin layers of the nezhnovoloknisty connecting fabric rich with blood vessels. Often to light cells cells with granular cytoplasm are added (granular), is more rare undifferentiated (spindle-shaped, polymorphic). Sometimes the last prevail (sarcoid option). In various departments the tumor can have an unequal structure. Quite often in P.'s adenocarcinoma there are centers of a necrosis and calcification.

Classical a wedge, signs of an adenocarcinoma of P. considered a hamaturia, pains in lumbar area, existence of the palpated tumor. However these symptoms making a so-called characteristic triad cannot be considered early display of a disease. Set of these signs is pointed to far come tumoral process by P. Klien, symptoms divide on renal and extrarenal, considering both those, and others typical for this disease. Carry a hamaturia, a pyuria to renal symptoms, a cylindruria), an albuminuria, pains in lumbar area of the aching character and type of renal colic, the palpated tumor; to extrarenal — fervescence, the accelerated ROE, anemia, increase in the ABP, a liver failure, a polycythemia) (hyperglobulia), an amyloidosis, to the varikotsela, weakness, a cachexia. In nek-ry cases P.'s adenocarcinoma is shown by paraneoplastic syndromes (see) in the form of a neyromiopa-tiya, a dermatosis, osteoarthropathies. They can develop in parallel a wedge, a picture of the tumor or after it, but sometimes advance a wedge, displays of a tumor.

The hamaturia at P.'s adenocarcinoma has total bezbolevy character. It is caused by an arrosion of vessels as a result of germination of a tumor that is observed in an end-stage of a disease, and a rupture varicose of expanded veins of the arch of cups at the expense of a prelum by a tumor of intra renal veins. Quite often total bezbolevy hamaturia is the only and precursory symptom of a malignant tumor of P. at its localization in a zone of large intra renal veins. The hamaturia can be followed by formation of clots. If they are formed in an ureter, then take the worm-shaped form, sometimes obturi-rut it that the wedge, is shown by a picture of renal colic. It is very important to reveal whether pain in lumbar area preceded a hamaturia or, on the contrary, it arose after bleeding that promotes differential diagnosis of an adenocarcinoma with a nephrolithiasis. Sometimes P.'s adenocarcinoma is shown by a microhematuria, edges is caused by insignificant bleeding from fornikalny veins. If the conducted examination did not allow to establish the reason of a hamaturia, it is necessary to undertake the complex of diagnostic testings directed to confirmation or an exception of the diagnosis of an adenocarcinoma of the Item.

Among symptoms of an adenocarcinoma of P. of special attention fervescence deserves. Fever at P.'s tumor long time was considered atipichesky display of a disease. Fervescence is the adverse symptom testimonial of far come process. However it quite often is the most precursory and only symptom of a disease. The hyperthermia at P.'s adenocarcinoma is explained with intoxication or reaction of an organism to a foreign protein. There is an opinion that fever at a tumor P. is caused by the strengthened secretion of the etiocholanolone produced by adrenal glands. Sometimes the adenocarcinoma is followed by inflammatory changes in P. and pararenal cellulose, up to formation of an anthrax, than it is also possible to explain fervescence. Fever at P.'s adenocarcinoma can have constant, gek-tichesky or intermittent character. After a nephrectomy body temperature is usually normalized. If the hyperthermia remains or there is through a nek-swarm time again, then it can be a sign of existence of metastasises.

Pain usually arises in far come cases and depends on involvement in tumoral process of surrounding fabrics and nerves. At defeat of nervous conductors pain simulates radiculitis, a sciatica. Sometimes the aching pains can be caused by a perifocal inflammation and the phenomena of a nephroptosis due to increase in weight of P. and its shift down.

The tumor defined at a palpation quite often is the only symptom of an adenocarcinoma of the Item. At P.'s tumors the symptom of balloting is observed. The immovability of a tumor can depend on inflammatory and cicatricial changes in pararenal cellulose. Except a palpation percussion allows to be guided in an arrangement of a tumor. The tympanic sound at percussion over a tumor indicates its retroperitoneal arrangement. At tumoral defeat of P. its surface can be equal and smooth. Lack of tuberosity does not exclude tumoral process therefore it is necessary to be careful in establishment of the diagnosis of a nephroptosis only on the basis a wedge, manifestations and data of a palpation.

At an adenocarcinoma it can be observed to a varikotsela (see) as a result of a prelum the tumor or its regional metastasises which are in retroperitoneal space, a yaichkovy vein. Varikotsele can arise also owing to the excess of a renal vein caused by a nephroptosis at P.'s increase in connection with growth of a tumor. If in position of the patient lying to a varikotsela does not disappear, then it indicates a resistant prelum of a yaichkovy vein.

Are observed the accelerated ROE and anemia, the hyperglobulia caused by toxic impact of a tumor on an erythrogenesis, and also a hypoxia of the renal fabric leading to the strengthened P.'s products of erythropoetin. More often the hyperglobulia is observed at an arrangement of a tumoral node in P.'s gate, existence of tumoral blood clot in a renal vein, i.e. owing to a hypoxia of a renal parenchyma.

In 25% of cases arterial hypertension is observed. The proof that arterial hypertension has nephrogenic character is normalization of the ABP after a nephrectomy.

Rather seldom at an adenocarcinoma the amyloidosis of the Item is noted.

At the same time changes in a type of a considerable proteinuria, a cylindruria can be the first displays of a disease. At 30% of P. sick with an adenocarcinoma find symptoms of a liver failure.

Most often the tumor gives metastasises in lungs, bones, regional limf, nodes, a liver, adrenal glands, a brain, in opposite P. Sravnitelno seldom metastasises are found in an ovary, a mammary gland, a wall of a vagina, a bladder, in heart, a spleen.

The diagnosis is based on a wedge, symptoms of a disease, data of laboratory, radiological, tracer, ultrasonic techniques of a research, and sometimes and data gistol, researches of the fabric received by a biopsy of a tumor or its metastasises.

Seldom at tsitol, a research of urine in it tumor cells can be found. More often it is observed at germination of a tumor in a renal pelvis. In urine find protein, erythrocytes, leukocytes, cylinders. During a gross hematuria it is possible to define a bleeding point by a tsistoskopiya that is important for assessment rentgenol, data.

Fig. 21. The selection renal arteriogramma: and — shooters specified the contrasted vessels in a tumor of a right kidney; — shooters specified spots of a contrast agent — the so-called lake or a puddle.

The leading diagnostic methods of an adenocarcinoma of P. are radiological. On the survey roentgenogram P.'s shadow with uneven contours is often visible, quite often in it the centers of calcification are defined. On the roentgenograms executed immediately after administration of contrast medium, the sizes P. are increased, contours uneven due to protrusion of a tumoral node. In 10, 15, 25 min. after administration of contrast medium defects of filling of renal cups or a pelvis, amputation of cups, their lengthening and shift can be observed. At localization of a tumoral node in one of poles of P. if the tumor is located below, the pelvis and cups are displaced up if it is above — from top to bottom. The ureter is usually rejected towards a backbone and quite often has bends because of P.'s omission at the considerable sizes of a tumor. For obtaining the best image of contours of P. reasonablly excretory Urografinum) (see) to combine with a tomography (see) or zonografiya. The retrograde piyelografiya (see) allows to receive the clear image of pyelocaliceal system, however its use is limited because of danger to cause innidiation of a tumor. The retrograde piyelografiya is usually applied when on excretory Urogramums it is not possible to receive the image of pyelocaliceal system. Administration of contrast medium in a renal pelvis in number of no more than 5 ml is made carefully, under low pressure not to cause a lokhanochno-renal reflux. Rentgenol. symptoms at a retrograde piyelografiya are similar to those which are observed on excretory Urogramums and also a pelvis consists in deformation and shift of renal cups. Ppnevmoretroperitoneum (see) and pneumoren (see) in connection with development of an angiography almost do not apply as low-informative. The renal angiography is of great importance (see), edges allows to distinguish the tumors of the small sizes located in cortical substance. Use of a complex of angiographic researches gives the chance not only to establish the diagnosis of a tumor of P., but also to define prevalence of process, involvement in it of a vascular leg, the lower vena cava, an aorta, and sometimes and regional paravazalny limf, nodes. Arteriography (see) and a flebografiya (see) give the valuable information allowing to determine the volume of operation and to make the plan of operational treatment. For diagnosis of a tumor of kidneys angiographic researches begin with an aortografiya (see). If this method does not allow to make the diagnosis, then inspection is continued, using the selection renal arteriography (fig. 21, a) and if necessary a pharmakoarteriografiya (see. Renal angiography). Characteristic rentgenol, symptoms of an adenocarcinoma of P. on arteriogramma are: increase in diameter of a renal artery, break near a tumoral node of branches of the first and second order, existence in the most tumoral node of shadows in the form of spots of irregular shape — a symptom of so-called lakes, puddles (fig. 21, b) owing to filling with a contrast agent varicose expanded vessels and an arteriovenous anastomosis of a tumor. In a parenchymatous phase of arteriography it is possible to observe even more clearly a tumoral node and to see its relation to the Item. Much attention should be paid to a venous phase of a renal angiography. Existence of an accurate shadow of a renal vein, edge remains on many roentgenograms, indirectly indicates the broken venous outflow from P. Eto most often is caused by a prelum of a renal vein a regional metastasis in limf, a node or tumoral blood clot. If on an arteriogramma the renal vein comes to light early, then it testifies about arteriovenous the shunt which is an indirect sign of an adenocarcinoma P. Urogra-ficheskaya the phase of arteriography allows to see changes in chashechnolokhanochny system and its relation to a tumor.

Fig. 22. The lower kavogramma at a tumor of a right kidney: and — shift a tumor of the lower vena cava to the left (it is specified by an arrow); a tumor of a right kidney with germination in the lower vena cava (shooters specified defect of filling of the lower vena cava).

After establishment of the diagnosis of a tumor of P. it is necessary to undertake a kavografiya (see) and the selection renal flebografiya. These researches allow to define prevalence of tumoral process. On a kavogramma the shift, defect of a wall of the lower vena cava or defect of its filling can be observed that indicates germination by a tumor or tumoral thrombosis (fig. 22). Existence of collaterals on a kavogramma speaks well for tumoral thrombosis of the lower vena cava. On the selection phlebogram the prelum of renal veins by a tumor, defect of their filling in the presence of a phlebothrombosis is observed. These data are very important for the choice of operational approach and scoping of operation. In the presence of regional metastasises on angiograms they come to light as defects of filling on a kavogramma and as a zone of hyper vascularization near an aorta on an aortogramma. On angiograms characteristic zones of hyper vascularization appear. Avaskulyarny tumors when even during the use of all arsenal of angiographic researches it is not possible to otdifferentsirovat a malignant new growth from P. V cyst these cases are seldom observed ultrasonic scanning allows to specify the dense or liquid nature of education (see. Ultrasonic diagnosis). Sometimes only test operation allows to finalize the diagnosis.

Radiodiagnosis of an adenocarcinoma of P. includes also recognition of metastasises of a tumor. The most characteristic signs of metastasises in lungs are roundish single or multiple spherical shadows. Pulmonary metastasises are quite often combined with tumoral defeats limf, nodes of lungs and a mediastinum. Metastatic pleurisy is less often observed. Metastasises in a bone have character of the osteoklastichesky centers without periosteal and endosteal reaction. Metastasises in metaphyses of tubular bones have an appearance of polycystic educations, remind bee cells, and sometimes they should be differentiated with a cystous osteodystrophy. At metastasises in tubular bones changes are quite often observed patol.

Tracer techniques of a research are approximate in recognition of an adenocarcinoma of P. Tsennost are of scanning (see) and an indirect isotope angiography of P. (see. Renografiya radio isotope ). On a skanogramma find defect of accumulation of radionuclide in a zone of an arrangement of a tumor of P. This symptom is not characteristic only of tumoral defeat since it is observed at a cyst and sclerous changes of a parenchyma. The indirect isotope angiography of P. which is carried out by means of the gamma camera gives more valuable data. In a zone of defect of the filling revealed on a skanogramma on the indirect isotope angiogram it is possible to observe the raised vascularization that gives the grounds to assume existence of a tumor.

Fig. 23. An echogram at a tumor of a kidney (lengthwise direction of scanning): 1 — the lower pole of a kidney, 2 — a pelvis, 3 — the upper pole is replaced with the big breaking-up tumor.

On echograms P.'s tumor comes to light as ekhopozitivny formation of oval or rounded shape, is frequent with uneven contours (fig. 23). In a zone of a parenchyma of P. come to light additional an echo structure. In case of a necrosis of a tumor and hemorrhages on an echogram along with sites of dense fabric liquid inclusions are defined. Great opportunities in establishment of the diagnosis and prevalence of process the computer tomography possesses (see the Tomography computer).

Fig. 24. The selection renal angiogram at a solitary cyst of a right kidney: shooters specified a zone of an arrangement of a cyst in which almost total absence of vessels comes to light.
Fig. 25. The computer tomogram at a tumor of a left kidney at the level of XII of a chest vertebra: a tumor of an upper pole of a kidney (it is specified by an arrow).

The differential diagnosis is carried out with a solitary cyst, a polycystosis (see above Malformations), a hydronephrosis (see), a nephroptosis (see), P.'s anthrax and retroperitoneal tumors (see. Retroperitoneal space, tumors). The solitary cyst of P. is often shown by the same symptoms, as a tumor. However on the angiogram in a zone of an arrangement of a solitary cyst of P. lack of vessels (fig. 24) is noted, and at an ekhografiya the liquid nature of education comes to light. Similar to it carry out the differential diagnosis at couple-pelvikalnoy (peripelvic) cyst. The essential help in differential diagnosis of an adenocarcinoma of P. with a solitary cyst and P.'s polycystosis is rendered by vascular methods of a research, ultrasonic scanning and a computer tomography (fig. 25). P.'s increase at a hydronephrosis forces to suspect a tumor. At the same time on Urogramums increase renal a pelvis and cups is observed that is not characteristic of an adenocarcinoma of a kidney.

On Urogramums at a nephroptosis due to P.'s rotation deformation of pyelocaliceal system is noted that does not allow to refuse the diagnosis of an adenocarcinoma finally. In these cases only vascular, ultrasonic methods of a research and a computer tomography allow to finalize the diagnosis. P.'s adenocarcinoma which is shown fervescence needs to be differentiated with acute pyelonephritis (see), P.'s anthrax, ksantogranu-lematozny pyelonephritis. Establishment of the diagnosis in these cases sometimes presents great difficulties since P.'s tumor can be combined with inflammatory changes, and rentgenol, symptoms of an anthrax of P. and a tumor on Urogramums are very similar. The angiography allows to carry out the differential diagnosis of an anthrax, ksantogranule-matozny pyelonephritis or P.'s tumor, the cut in arteriogra-fichesky and parenchymatous phases in the location of an anthrax of P. decides on the help defect of filling of vessels and a parenchyma.

Differential diagnosis with retroperitoneal tumors, coming from nervous tissue (a neurinoma, a ganglioneuroma, a simpatikoblastoma) is difficult, at to-rykh P. it is involved in process for the second time, being exposed to the shift, a prelum or germination by a tumor. Such retroperitoneal tumor can reach the considerable sizes, often has the capsule; fabric it on a section of grayish-red or pale gray color, at disintegration with the centers of a necrosis and hemorrhages. It is clinically shown by pains in hypochondrium and lumbar area, sometimes a hamaturia, a hyperthermia and arterial hypertension. On excretory Urogramums and at a retrograde piyelografiya considerable comes to light, the shift of the Item is more often medial. Deformation of pyelocaliceal system is observed seldom and is caused by the shift of the Item. At an aortografiya P.'s removal is defined by usually avascular education more accurately. At an ekhografiya in case of disintegration of a tumor quite often along with dense structures liquid comes to light. Quite often final diagnosis is established only at gistol, a research of a tumor.

Fig. 26. Embolization of a renal artery by means of Gianturko's spiral: and — an arteriogramma the struck tumor of a right kidney before embolization; — embolization is made, the spiral is specified by an arrow, the pyelocaliceal system is contrasted.

Radical method of treatment is the nephrectomy (see). Requirements of an ablastichnost and radicalism are imposed to the operation which is carried out concerning P.'s tumor. The Ablastichnost is reached by preliminary bandaging of renal vessels and P.'s removal by the uniform block with perinephric cellulose and adjacent leaves of a fascia of P. Radikalnost provides performance of whenever possible expanded nephrectomy (a limfadenektomiya periaortal and pericaval limf, nodes, a thrombectomy from the lower vena cava, bowel resection or a gemikolonektomiya, a resection of a liver, a diaphragm, etc.). To P.'s mobilization carry out bandaging of renal vessels — in the beginning tie up a renal artery, and then a renal vein. Otherwise there can occur acute increase in intravenous pressure that promotes distribution of tumor cells on a collateral to expanded veins ny varicose. At impossibility of separate bandaging of renal arteries and veins tie up them at the same time. For the termination of inflow of blood to P. use also artificial embolization of a renal artery (see. X-ray endovascular surgery ), to-ruyu make more often under peridural anesthesia by means of a cylinder, clots of autologous blood, pieces of muscles, thrombin, Gianturko's (fig. 26) spiral, etc. Embolization of a renal artery is applied to reduction of blood loss at a nephrectomy and as an independent method of treatment at neudalimo of a tumor or at patients, the Crimea operation cannot be made because of a serious general condition.

For a nephrectomy concerning P.'s tumor use various quick accesses — on Nagamatsa with removal of segments X, XI, XII of edges, intraperitoneal accesses, a torakofrenolaparotomiya in the eighth, ninth and tenth mezhreberye. Intraperitoneal accesses and a torako-frenolaparotomiya create favorable conditions for preliminary bandaging of vessels, audit pericaval and periaortal limf, nodes and, in need of their removal, implementation of a nephrectomy together with surrounding cellulose and fastion the uniform block. Use lumbotomies (see) for the purpose of P.'s removal, the hit tumor, it is impossible to consider justified since at the same time bandaging of renal vessels before mobilization P. is impossible.

The immovability of a tumor of P. and existence of single metastasises are not contraindications to operational treatment. The immovability of a tumor can be caused by a perifocal inflammation, and single metastasises can be removed in the operational way. At a motionless tumor operation is begun with a laparotomy and audit. Metastasises in a liver, conglomerates of metastasises in pericaval and periaortal limf, nodes and germination of a tumor in surrounding bodies and fabrics do a nephrectomy inexpedient. At the multiple remote metastasises the nephrectomy is shown only in cases of a profuse hamaturia for the purpose of a stop of bleeding and when it does not represent a big injury for the patient and there is a hope in the subsequent for effect of chemotherapy.

Special difficulties arise in definition to lay down. tactics at patients from anatomically and functionally only P. Izvestna cases with favorable results of organ-preserving operations (P.'s resection, enucleation of a tumoral node or a tumorektomiya).

Along with operational treatment apply radiation therapy and appoint antineoplastic means. These methods are auxiliary, and use their hl. obr. in the combined treatment. Use remote gamma devices to performing radiation therapy (see) and particle accelerators (see). Surely include the struck P. or its bed in a zone of impact of ionizing radiation and regional limf, nodes. Carrying out within 4 days of preoperative radiation therapy in a total focal dose of 2000 is recommended I am glad (20 Gr) and performance of operation on 1 — 3 days after the end of radiation. In cases of not radical oncotomy carry in addition out postoperative radiation in a total dose 3000 I am glad (30 Gr) for 3 — 4 weeks. Apply also only postoperative radiation at germination of a tumor in renal veins or the fibrous capsule P., existence of metastasises in regional limf. nodes. The total focal dose at the same time shall reach 4500 — 5000 is glad (45 — 50 Gr) and is brought for 4 — 5 weeks.

At the radiation therapy applied independently the absorbed focal dose makes 5000 — 6000 is glad (50 — 60 Gr) and is brought for 5 — 6 weeks.

The forecast is adverse, however 5 years later after a nephrectomy concerning P.'s adenocarcinoma there live 32 — 45% of patients.

Cancer tumors of a renal pelvis meet much more less than tumors of a parenchyma of P. Imeyutsya of the instruction on developing of tumors of a renal pelvis at the excessive use of analgetics, especially acetphenetidiene.

The tumor is localized in a renal pelvis, can fill completely it, extend in renal cups, sometimes burgeoning in a renal parenchyma (tsvetn. fig. A. 7). According to the WHO classification allocate the following forms of cancer of a renal pelvis: 1) transitional cell cancer; 2) options of a Schmincke's tumor (with a planocellular metaplasia, a ferruterous metaplasia, a planocellular and ferruterous metaplasia); 3) planocellular cancer; 4) adenocarcinoma; 5) undifferentiated cancer. The Schmincke's tumor which is found most often usually grows ekzofitno in a type of the education reminding macroscopically a cauliflower. In 20 — 30% of cases the combination to similar tumors or papillomas of other departments of uric ways is observed. Occasionally the urothelial carcinoma of in situ meets. Planocellular cancer is often combined with nefrol itiazy, hron, pyelonephritis, a leukoplakia of a renal pelvis. In 60 — 65% of cases on opening germination of cancer of a renal pelvis in P. or surrounding fabrics, in 80 — 85% — metastasises comes to light, it is preferential in a liver, limf, nodes and lungs.

A wedge, displays of a disease are the hamaturia, pains in the field of the struck P. Palpirovat education works well in case of a hydronephrosis.

In diagnosis of tumors of a renal pelvis the excretory urography and a retrograde piyelografiya have the greatest value, at to - ry defect of filling in a renal pelvis comes to light. There are instructions on a possibility of identification patol, vessels for the basis of a tumor at the selection renal arteriography. The diagnosis can be confirmed at tsitol, a research of an urocheras, in Krom sometimes find atipichesky cells. Emergence of bloody urine during the passing of a beak of an ureteric catheter through a tumor (a symptom of Shevassyu) also testifies to a tumor of a renal pelvis.

In differential diagnosis most often there is a need to distinguish an uratny nephrolithiasis and a papillary tumor of a renal pelvis. Along with assessment clinical and rentgenol, symptoms establishment of the diagnosis is promoted by the research pH of urine and a salt deposit. At a nephrolithiasis use of also ultrasonic scanning since echo signals of an urinary stone unlike a papillary tumor accurately are registered is possible.

Treatment — operational, consists in a nephroureterectomy (see the Nephrectomy) with a cystectomy together with the mouth of the corresponding ureter. As indications to organ-preserving operations bilateral defeat of P. or a papillary tumor only the Item can serve.

The forecast — doubtful. The postoperative lethality at a single-step nephroureterectomy makes 5%. Five-year survival after operational treatment concerning a Schmincke's tumor of a pelvis makes 30 — 40%, ten-year-old — 20 — 25%. The operated patients are subject to the dispensary observation including a control tsistoskopiya each 3 months in the first 2 years, each 6 months — in the next 3 years and once a year in 5 years after operation.

Sarcoma of a kidney meets seldom. Are characteristic of it rapid growth, especially in renal veins, early and wide innidiation. Macroscopically it is, as a rule, a large tumor, pale gray on a section (tsvetn. rice. And. 8), the consistence a cut can be soft (liposarcoma) or dense (fibrosarcoma). The principles of diagnosis and treatment of sarcoma the same P. that are described above for an adenocarcinoma. Forecast adverse.

OPERATIONS

Kidneys have the developed nervous bonds with neuroplexes of abdominal organs therefore an operative measure can be followed by the expressed neurovegetative reactions and demands reliable anesthesiology protection. Position of the patient on one side breaks return of a venous blood to heart, worsens conditions of ventilation of the lungs, increasing the venous shunt. Spontaneous breath at this position of the patient does not provide sufficient gas exchange and therefore preference is given to an endotracheal anesthesia using muscular relaxants and carrying out artificial ventilation of the lungs (see. Inhalation anesthesia ).

For the purpose of decrease in operational risk at patients beforehand korrigirut the available functional frustration. Weight of a condition of patients depends on character of a basic disease, existence of the accompanying pathology, extent of disturbance of homeostatic function P. Patients with a renal failure along with accumulation of nitrogenous products of metabolism have disorders of water and electrolytic and acid-base balance, dysfunctions of breath and blood circulation join.

The renal failure and the frustration of a homeostasis caused by it impose specific specific requirements to the choice of means and methods of the general anesthesia. Anesthetic shall have the sufficient narcotic width and easy controllability, shall not have nephrotoxic effect, collect in an organism and break metabolism. Nembutal, Dimedrol, Seduxenum can be appointed to night on the eve of operation. For premedication include atropine, Suprastinum, Promedolum in number of means (at pains) in 10 — 15 min. prior to an introduction anesthesia. For an introduction anesthesia it is possible to use Thiopentalum-natrium or hexenal in a dose of 4 — 6 mg/kg, viadril — 8 — 10 mg/kg, Sombrevinum — 500 mg, Ketaminum — 2 — 2,5 mg/kg (at hypertensia Ketaminum needs to be applied with care or to exclude completely). For maintenance of an anesthesia the combination of nitrous oxide with oxygen (2:1), with ether either with Ftorotanum, or about Droperidolum of ohms, fentanyl is reasonable. Preference is given to muscle relaxants of the depolarizing action, at transplantation of a kidney it is more reasonable to apply Muscle relaxants of the anti-depolarizing group.

From complications of the general anesthesia it is necessary to point to dangerous postural reactions of blood circulation. Warn them adequate anesthesia, correction of a hypovolemia, careful laying of patients on the operating table. The nephrectomy at big tumors of P. can be followed by considerable blood loss and hormonal insufficiency; at an excess transfusion of liquid at patients with a renal failure there can come the overload of heart and a fluid lungs. Strict dosing in these conditions is demanded also by drugs of potassium and cardiac glycosides.

Operational approaches to P., exposure and interventions on it carry out various accesses: ekstraperitonealny, abdominal and transthoracic. In nek-ry slguchayakh, napr, at big tumors, use the combined access to P. — torakoab-dominalny, including with a section of a diaphragm (torakofrenolaparoto-miya). The majority of operations on kidneys make by means of extra peritoneal approach — the lumbotomy (see) which is carried out by Fedorov's cuts, Bergmann — Izrael, Kyuster; apply Simon's cuts, Pean, Common people less often (see fig. 5 to the Art. « Lumbar area »), Rosenstein.

At operations on P. the patient is stacked on the operating table sideways, opposite to the party of an operative measure. Usually enclose the roller that facilitates access to the Item. After a section of skin and a fatty tissue cut muscles and bare retroperitoneal space. During the use during anesthesia of muscular relaxants sometimes apply intermuscular accesses to a kidney — drawing apart muscles on the course of fibers, napr, across Spasokukotsky, Frumkin, Pogorelko, Lurtsu, Rosenstein.

Fig. 27. Diagrammatic representation of the main stages of operation of decapsulation of a kidney: and — a slit of the fibrous capsule on a fluted probe — stupid amotio of the fibrous capsule from a parenchyma of a kidney.

P.'s decapsulation (removal of the fibrous capsule) is applied at acute purulent pyelonephritis (apostematous nephrite), a perinephritis. As a result of this operation it is possible to drain abscesses, to reduce intra renal pressure and to improve blood circulation and a lymphokinesis in the Item. After P.'s exposure on its lateral edge make a slit of the fibrous capsule. Enter a fluted probe into a section and on it, raising the capsule, cut it. Then edges of the capsule otslaivat from a renal parenchyma up to P.'s (fig. 27) gate. To excise the fibrous capsule there is no need. Often decapsulations) combine kidneys with other operations, napr, a nephrostomy (see. Decapsulations of a kidney ).

Nephrotomy (see) — a section of a renal parenchyma, make for the purpose of removal from P. of stones, foreign bodys, for performance of a nephrostomy. and sometimes and with the diagnostic purpose. The extensive nephrotomy is combined with a nephrostomy.

Nephrostomy (see) — imposing of fistula on a kidney, provides drainage of pyelocaliceal system.

The transdermal puncture nephrostomy finds application, edge it is more preferable than a usual nephrostomy at the weakened heavy patients when it is impossible to recover passability of an ureter. Operation is made under local anesthesia. The direction of a needle is controlled by means of ultrasonic scanning or television roentgenoscopy for what visualize pyelocaliceal system by intravenous administration of radiopaque substance. Apply a needle trocar 9 cm long to a puncture and to dia. 1,5 mm. The puncture is made on the back axillary line under the XII edge. As the proof of a successful puncture serves the effluence on a needle trocar of urine. Then enter into a renal pelvis on a trocar the metal conductor and on it a plastic drainage tube. For expansion of the nefrostomichesky channel each 2 — 3 days replace a tube new, and them gradually increase diameter to 3,5 mm. Change of a drainage tube is made with use of the metal conductor. In the subsequent on a nefrostoma enter a constant catheter of Foley No. 12 which is left for a long time into a renal pelvis.

The nephropyelostomy ring-shaped drenazhy, consisting in carrying out a drainage tube through wounds of a renal pelvis and P., is applied seldom in connection with possible complications up to eruption of a drainage tube through a renal parenchyma.

Piyelotomiya (a section of a renal pelvis) is made for extraction of stones from a pelvis and renal cups and as a component of other operations on a renal pelvis. Depending on the place of a section of a pelvis distinguish a front, lower, back and upper shtelo-tomiya. The front piyelotomiya is difficult because of a close arrangement of renal vessels. It is applied only at a big extrarenal pelvis or at abnormal P. when the renal pelvis is located in front of and away from large vessels. Make a back piyelotomiya more often. Allocating a back wall of a renal pelvis at its intra renal type, remove a back lip of P. that usually works well at the developed renal bosom. On an inner surface of a renal lip, and sometimes and on its bottom edge are located and. and v. retropyelicae which at the same time can be damaged. The section of a wall of a renal pelvis is made in cross, is more rare in lengthwise direction. During removal of big and especially korallovidny urinary stones sometimes cut not only a renal pelvis, but also a renal cup; such operation carries the name of a piyelokalikotomiya.

At intra renal type of a pelvis in case of an arrangement of urinary stones in it and the lower big renal cup apply the lower piyelotomiya. After allocation of the lower pole of P. and an upper part of an ureter otslaivat a pelvis and remove a hook of a knaruzha the lower pole of the Item. The lower surface of a pelvis is as a result bared, to-ruyu cut longwise or cross, without breaking integrity of a lokhanochno-ureteric segment. From a pelvis and cups apply a verkhnepoperechny piyelotomiya to removal of big urinary stones, at a cut the wound of a pelvis reminding the opened beak of a bird is formed. Expand with the consecutive shift of bottom edge of a pelvis from a stone a wound and delete a stone. After a piyelotomiya the wound of a pelvis is taken in catgut seams or if it is technically impossible, well drain a wound. For this purpose the rezinovomarlevy graduates or thin drainage tubes entered to the place of opening renal a pelvis and cups in a bottom corner of a wound apply.

P an iyelostomiya (see) — imposing of fistula on a renal pelvis. This operation is made less than nephrostomies). After a section of a renal pelvis enter a rubber drainage tube into it, to-ruyu fix a catgut seam to edges of a wound in a wall of a pelvis.

Fig. 28. Main stages of a resection of an upper pole of a kidney: and — a kidney after a resection of a pole; — a kidney after the final stage of operation, the stitches on the fibrous capsule squeezing a parenchyma of a kidney are put.

P.'s resection (removal of part P.) make at tuberculosis, damages, a hydrocalycosis, a solitary cyst, fornikalno-cup bleeding, at the only P.'s tumor, various diseases of the doubled P. and some other. Resect one of poles of P. (fig. 28) more often, is more rare its middle part. Prepost mobilization of a vascular leg in case of need to impose a soft clip on vessels and to execute operation without blood. It is sometimes possible by P.'s prelum fingers or the soft clip imposed tsentralny the resected renal segment. If there is separately going arterial vessel to P.'s pole which is subject to a resection, then it is tied up that considerably facilitates performance of operation. After excision of a pole of P. make an obshivaniye and bandaging of small vessels of a parenchyma and sewing up of a renal cup and a pelvis. Sometimes after a resection resort to a tamponade of a renal wound pieces of muscular or fatty tissue. If at P.'s resection broad opening of pyelocaliceal system took place, then make nephrostomies). At defeat of one of half of the abnormal doubled P. apply a geminefrektomiya, the edge practically does not differ from P. Anomalno's resection the located renal vessels tie up in close proximity to the deleted part P.

Along with P.'s resection at cavernous tuberculosis apply a cavernotomy. After a puncture of the fluctuating site and receiving pus open with a section on an outer surface of P. a purulent cavity in a parenchyma, delete the caseous masses and sometimes a piogenic cover. The cavity of a cavity is processed solution of trichloroacetic acid. In certain conditions the cavernotomy has advantage before P.'s resection as at the same time the most part of the functioning parenchyma remains.

Fig. 29. Main stages of a nephrectomy: and — the ureter is tied up and crossed, imposing of the general ligature on vessels of a kidney; — imposing of clips on vessels of a kidney; in — the kidney is removed, underrunning of vessels for the subsequent their bandaging is carried out.

The nephrectomy (see) — P.'s removal, is made at malignant tumors, extensive damages of P., in far come stage of a hydronephrosis, inflammatory (purulent) processes in P., at nephrogenic hypertensia, before renal transplantation. Items allocate from surrounding fabrics, will mobilize a vascular leg, on to-ruyu impose catgut ligatures. Tsentralny ligatures on a leg impose Fedorov's clip then the vascular leg is crossed. The ureter is tied up in its upper third and crossed between two ligatures. After P.'s removal the vascular leg tsentralny the clip imposed on it is in addition stitched and tied up a catgut (fig. 29).

Nephrectomies) at P.'s tumors carry out with observance of requirements of an ablastichnost in this connection more and more broad application is found by a torakofrenolaparotomiya. The patient is stacked on the operating table slightly having turned sideways for what under a shovel and a buttock on the party of operation enclose rollers 8 — 10 cm high. A section X or XI edges will see him to the front end from the back axillary line on the upper edge, and then on a front abdominal wall to a midline. The outside oblique muscle of a stomach and intercostal muscles are cut, open a pleural cavity, the direct muscle of a stomach is removed or crossed. Then make a diaphragmotomy. At operation on the right P. cut the right triangular and hepatonephric sheaves and remove up a liver. The back leaf of a peritoneum is cut parallel to the descending part of a duodenum and the right bend of a colon which remove medially then bare lower hollow and right renal veins. At operations on the left P. cut a back leaf of a peritoneum parallel to the descending colon and the left bend it in the beginning, cross phrenic and colic and selezenochno-renal sheaves. The descending colon is taken away medially then bare a renal vascular leg and an aorta. Carry out whenever possible separate mobilization renal arteries and veins and stop arterial inflow to the Item. After bandaging and a section of a renal artery press, cross and tie up a renal vein. After crossing of an ureter and a resection of a back leaf of a peritoneum over a tumor make nephrectomies) the uniform block with perinephric cellulose, front Pi back leaves of a renal fascia and with the adjacent site of a peritoneum.

At papillary tumors of a renal pelvis along with a nephrectomy make an ureterectomy (see the Ureter, operations) with a cystectomy together with the mouth of the corresponding ureter. It is reasonable to make such operation by means of two cuts. By a lumbar section make nephrectomies) and inguinal and ileal — an ureterectomy and a cystectomy.

The nephropexy (operation of fixing patholologically mobile P.) is shown at a nephroptosis (see). Various ways of a nephropexy with P.'s fixing to edges deprive of it fiziol, mobility. This shortcoming is to a greater or lesser extent inherent in a nephropexy according to Fedorov and Albar-ranu — to Marion, Lousli, and also various modifications with P.'s fixing for the fibrous capsule. Gorash's operation is more effective (sewing up of the dispersed leaves of a renal fascia at the lower pole of P.). The greatest distribution was gained by methods of a nephropexy the muscular rag on a leg taken from big a poyasnichnor! muscles. Apply Rivuar's operation in different modifications more often. The best results are yielded by a nephropexy by Rivuar's method in A. Ya. Pyte-l and N. A. Lopatkin's modification. At the same time the muscular rag is carried out subkapsulyarno on a back surface of P. and, having rounded its lower pole, fix the end of a rag on a front surface of body noose silk sutures to the fibrous capsule P. It reaches P.'s fixing in normal situation on its longitudinal axis.

Plastic surgeries on a lokhanochno-ureteric segment apply at treatment hydronephrosis (see).

Enterorevaskulyarization P. was applied for the purpose of creation of roundabout inflow of blood to P., elimination of the complicated lymph drainage at the nephrogenic hypertensia caused hron, pyelonephritis earlier. Previously it was made P.'s decapsulations, then the segment of a jejunum with preservation of its mesentery was resected and the prokhodrshost of intestines was recovered. The resected intestinal segment was cut on length, deleted from it a mucous membrane and a submucosa and after that the rag was hemmed to P. on all its surface.

Concerning the renovascular hypertensia caused by a renal artery stenosis and its branches apply plastic, reconstructive surgeries on a renal artery: a resection of the narrowed segment of an artery with connection of an artery the end in the end, an endarteriektomiya (excision of atheromatous plaques rtz walls of an artery with recovery of its gleam), shunting of an artery with an aorta, a splenorenalny arterial anastomosis, a chrezaortalny endarteriektomiya from the mouth of a renal artery, a resection of a renal artery with plastics autoarteriy or autoveny, bypass shunting. In cases when arterial hypertension is caused by a stenosis of a renal vein, the paravase of lny hems and commissures, P.'s fixing in fiziol, situation make plastic correction of a trunk and the mouth of a renal vein, excision.

Operations at a solitary cyst of P. are shown only at cysts of the big size or suspicion of a tumor in a cyst. After P.'s exposure the cyst is punktirut a needle and receive pz it liquid. The wall of a cyst is cut, make audit of her cavity then delete a part of a wall of a cyst on border with not changed renal fabric. The inner surface of the rest of a cyst is coagulated solution of formalin. Edges of the excised cyst stitch a continuous catgut suture, stopping bleeding, a cut usually happens insignificant. Bring a drainage to P.

Operation at P.'s polycystosis is absolutely shown at suppuration of cysts, and also at a nephrolithiasis and big cysts in gate of P. breaking intra renal blood circulation at patients with the kept function P. After an exposure of the lower pole of P. make a puncture small and excision of large cysts. In process of elimination of cysts in the lower pole become available to excision of a cyst of an average segment, and then and an upper pole. Will especially carefully mobilize and excise cysts in the field of P.'s gate as these cysts generally cause frustration of a hemodynamics and serve as the reason of arterial hypertension. Excision of cysts in the field of P.'s gate is made with the maximum care because of a possibility of injury of a renal vein or a renal pelvis. After excision of cysts bring 3 — 4 rubber and gauze drainages to P.; drainage of a wound shall be reliable and rather long. 4 — 6 months later similar operation make on other Item.

Renal transplantation (see) from the donor took the important place in treatment of patients in an end-stage hron, a renal failure, and also the persons which lost P. as a result of an injury, etc.

The microsurgical equipment provides performance of extracorporal operations on P. for renovascular hypertensia, new growths, for the purpose of P.'s transplantation, etc. Improvement of the microsurgical equipment expands possibilities of performance of extracorporal operations on kidneys.




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A. Ya. Pytel, S. I. Ryabov, V. S. Timokhov; Yu. G. Alyaev (PMC., hir.), E. G. Aslamazov (paraz., a leukoplakia of a renal pelvis, displacing lipomatoz), H. E. Burov (anest.), Yu. E. Veltishchev (ped.), R. I. Gabuniya (tracer techniques of a research), G. V. Goldobenko (I am glad.), A. P. Yerokhin (malformations), V. V. Kupriyanov (An., gist., comparative anatomy and physiology, embr.), V. V. Mazin (disturbance of blood circulation, damage), Yu. V. Natochin (physical., comparative anatomy and physiology), V. M. Perelman (rents.), Yu. A. Pytel (PMC., hir.t, M. Ya. Ratner (mt. issl.), V. A. Samsonov (morphology of tumors), V. V. Serov (stalemate. An.), I. P. Shevtsov (soldier., mt. issl.), G. A. Zubovsky (stsintigramma — tsvetn, fig. 1 — 6), V. A. Romanov (tsvetn, fig. 1 — 9).

Яндекс.Метрика