PYELONEPHRITIS

From Big Medical Encyclopedia

PYELONEPHRITIS (pyelonephritis; grech, pyelos a trough, a tub + nephrite) — nonspecific inflammatory process with preferential defeat of intersticial tissue of kidney and its pyelocaliceal system.

Clinical physicians refused the term «pyelitis» because there is no isolated defeat of a pelvis (a renal pelvis, T.). As in initial stages of P. the picture of intersticial nephrite is morphologically observed (see), nek-ry urologists suggest to designate such disease of the term «intersticial nephrite». However despite morfol, identity of this form of nephrite and P., nevertheless it is more reasonable to use the term «pyelonephritis» since it most correctly reflects pathogenetic, morphological and clinical essence of a disease. In some cases, when primary inflammatory center arises in a bladder, use the term «tsistopiyelonefrit».

Distinguish acute and chronic P.

Statistics

P. — the most frequent disease kidneys (see). The analysis of the big pathoanatomical material presented by Dutts (N. Dutz) and soavt. (1968), showed that in 6 — 18% of all openings signs hron were established. P. U of P. women is observed twice more often than at men. In 75% of cases the disease at women arises aged up to 40 years, at the majority during pregnancy. Men of advanced age get sick with P. more often than women; generally it is caused by disturbance of urodynamic owing to adenomas of a prostate (see) and other diseases of urinogenital system. Children most often get sick with P. aged up to 3 years, and the girl by 3 times more often than boys.

According to Dicherlayn (G. Dit-scherlein, 1969), P. develops at 25,7% of the persons suffering from a diabetes mellitus. Almost at 40% of the patients having a nephrophthisis also pyelonephritis is observed at the same time. To the contrary, emergence of a tuberculous focus in the kidney which is earlier affected with the Item is possible. According to A. Ya. Yaroshevsky (1971), to D. Sclione with sotr. (1974), in 9 — 10% of cases glomerulonephritis (see) the Item joins. Increase of cases of P. and its frequent atypical current is in recent years noted. It is caused not so much by improvement of diagnosis, how many sharply increased virulence of microorganisms as a result of the resistance to antibiotics acquired by them, and also change of a current inf. process in a kidney owing to suppression of immune responses at an antibioticotherapia, existence at patients of a sensitization and superinfection.

Classification

Distinguish primary and secondary Item. Primary P. is called differently uncomplicated, secondary — complicated, and by nek-ry clinical physicians — obstructive. Primary P. is observed in 20%, secondary — in 80% of cases among all sick Items.

Primary P. is preceded by no disturbances from kidneys and uric ways; the organic or functional processes in kidneys and uric ways reducing the resilience of renal fabric to an infection and breaking a passage of urine are the cornerstone of secondary P. Depending on that, it is affected one or two kidneys, allocate P. unilateral and bilateral. On character of a course of process of P. divide on acute (serous and purulent), chronic and recurrent. Depending on a way of spread of an infection distinguish P. hematogenous and urinogenny (ascending). Besides, P.'s current can have the features connected with age the patient, change of its general physiological state, presence of another patol, process; in this regard allocate: The item of children's age (including at newborns), P. at people of advanced age, at patients with a diabetes mellitus, glomerulonephritis, at patients with damage of a spinal cord, P. at persons with the replaced kidney (so-called pyelonephritis of a transplantirovanny kidney).

The etiology and a pathogeny

In emergence and P.'s development play a role many factors among which special value have an appearance and character of a contagium, existence of changes in a kidney and the uric ways promoting fixing in them of contagiums and development of process, a way of penetration of contagiums to a kidney, the general condition of an organism, it immunobiol. reactivity.

Activators P. are preferential colibacillus, staphylococcus, proteas, representatives of the sort Klebsiella, psevdomonas, are more rare enterokokk, a streptococcus; often the mixed flora takes place.

At patients with acute P. in urine define pure growth of colibacillus in 49%, the mixed flora (colibacillus, staphylococcus, proteas and enterokokk) — in 35%, staphylococcus — in 10%, staphylococcus and a streptococcus — in 5% of cases. At patients hron. Items find pure growth of colibacillus in 25%, mixed (colibacillus, staphylococcus, a streptococcus, proteas, etc.) — in 68%, only coccal flora — in 6% of cases. It is proved that species composition of microflora at P. changes owing to antibacterial therapy (microorganisms, earlier almost not meeting are often sowed); changed and biol, properties of activators, get etiol, L-forms value of bacteria, especially at emergence hron. Item and its aggravations.

Primary centers of contagiums from where they can be brought in a kidney, any pyoinflammatory processes are (caries of teeth, pneumonia, a furunculosis, mastitis, cholecystitis, osteomyelitis, the inflammatory centers in bodies of urinogenital system, etc.).

There are next ways of penetration of contagiums to a kidney: hematogenous, on a wall of an ureter, on its gleam in the presence of vesicoureteral reflux (see).

In clarification of the mechanism of penetration of contagiums into tissue of a kidney and development in it inflammatory process the big role was played by the doctrine about lokhanochno-renal refluxes.

Two conditions are necessary for penetration of contagiums from a pelvis in a parenchyma of a kidney: disturbance of an integrity of an urothelium in a forni-kalny zone of a cup and the increase in intrapelvic pressure which is a consequence of disturbance of outflow of urine — a vesicoureteral reflux. Penetration of an infection into a parenchyma of a kidney can happen also without damage of an urothelium of a for-niks — a canalicular way to the subsequent transition inf. the agent from tubules in intersticial fabric.

Infection of a kidney with a hematogenous way happens as follows: microorganisms from a pelvis get into the general blood flow on venous or limf, to vessels of a kidney, and then, having returned on arterial system to the same kidney, cause in it inflammatory process. Essential value in P.'s development has a sclerosis of fatty tissue of a renal sine (a renal bosom, T.), caused by intermittent piyelosinusny refluxes. Arisen owing to this fact pedunkulit (see) brings to limf, and to a venous staz in a parenchyma of a kidney. The venous plethora adversely affects a lymph drainage from a kidney and promotes disturbance of permeability of a vascular wall with the subsequent penetration of microorganisms into fabric. The hematogenous way takes place not only in the presence inf. the center in the remote bodies and fabrics, but also at its localization in urinogenital system. Microorganisms from bodies of this system can get on limf, to vessels into the general circle of blood circulation and to be brought in a kidney. Penetration into a kidney inf. the beginning on limf, is not proved to vessels from intestines.

Abacterial intersticial can precede primary bacterial P. nephrite (see). Combinations of allergic, chemical, physical and bacterial factors create an originality a wedge, displays of a disease. It is necessary to refer adverse influence to pathogenetic factors of intersticial nephrite and some medicines, their metabolites (streptocides, antitubercular drugs, vitamin D in high doses, acetphenetidiene, analgetics). The item, Krom are preceded by abacterial intersticial nephrite, occurs preferential at adults. P.'s development in children is promoted by a dysplasia of kidneys.

Have an essential role in P.'s development funkts, and morfol, and finishing the changes of uric ways of the inborn and acquired character leading to disturbance of urodynamic since nephron an urethra. At patients with disturbance of a passage of urine P. it is observed 12 times more often, at the same time preferential purulent forms acute P.

Hron develop, P.'s current is in many respects caused immunopato by l. process. Bacterial antigens, remaining in a parenchyma of a kidney after disappearance of viable microbes for a long time, promote progressing of the Item.

Along with local factors in P.'s emergence weakening of protective forces of an organism, a hypovitaminosis, disturbance of a trophicity, neurohumoral disorders, diseases of a liver, vascular system, a diabetes mellitus, gout, a nephrocalcinosis, insufficiency of potassium, abuse of analgetics (acetphenetidiene, etc.), the extrarenal centers of an inflammation (enteritis, quinsy, etc.), inflammatory processes of urinogenital system matter.

The pathological anatomy

P. differs in focal and is more often hemilesion of kidneys. Even at bilateral defeat extent of changes in various departments of body happens unequal. Considerable difficulties are presented gistol, by differentiation urinogenny and hematogenous P.

Razlichayut P. focal and diffusion. Macroscopically kidneys at focal acute P. have no specific changes, at diffusion defeat they can be bulked up with a little expanded and flabby cortical substance and a hyperemic mucous membrane of a pelvis.

Fig. 1 — 6. Microdrugs of kidneys at pyelonephritis. Fig. 1. Serous pyelonephritis: the hyperemia of a microcirculator bed, expanded veins are filled with the erythrocytes painted in brown color; coloring across Lepena; X80. Fig. 2. Focal purulent pyelonephritis: the center of a purulent inflammation (it is specified by an arrow); coloring hematoxylin-eosine; X80. Fig. 3. Acute purulent pyelonephritis: purulent cylinders in tubules of kidneys (are specified by shooters); coloring hematoxylin-eosine; X 80. Fig. 4. Acute purulent pyelonephritis: colonies of microbes (blue color) in a gleam of tubules of kidneys; coloring hematoxylin-eosine; X 80. Fig. 5. Acute purulent paranephritis: leukocytic infiltration of perinephric cellulose (it is specified by an arrow); coloring hematoxylin-eosine; X 80. Fig. 6. Purulent pyelonephritis: layer of a desquamated epithelium of a pelvis (it is specified by an arrow); coloring hematoxylin-eosine; X 80.

At acute serous P. hypostasis of a stroma of brain and cortical substance, a plethora of a microcirculator bed is noted (tsvetn. fig. 1), dystrophic-nekrobio-ticheskiye changes of an epithelium of proximal and distal tubules, dilatation of their gleam. In zones of the maximum tubuloegshtelialny defeats in composition of stromal exudate there is an impurity of polymorphonuclear leukocytes. Balls remain intact.

At focal purulent P. peritubulyarny or intra-tubular accumulations of polymorphonuclear leukocytes, a cellular detritis and homogeneous proteinaceous masses within several nephrons are observed (tsvetn. fig. 2 and 3). At diffusion purulent P. destruction of walls of tubules (tubulorrhexis), and sometimes and capsules of balls (an invasive glomerulitis) with formation of uric zatek can be noted.

In a gleam of expanded tubules proteinaceous and leukocytic cylinders and colonies of microbes are visible (tsvetn. fig. 4). Progressing of a purulent inflammation can come to the end with the apostematous nephrite isolated by the abscess or an anthrax of a kidney representing extensive sites of the merging abscesses and centers of a necrosis. The anthrax of a kidney quite often is complicated by a purulent paranephritis (tsvetn. fig. 5). At patients with a dekompensirovanny diabetes mellitus of P. can be complicated by a necrosis of nipples of pyramids (see. Renal nipples necrosis ).

And postematozny nephrite (see), developing more often at staphylococcal sepsis owing to generalization of an infection from extrarenal sources, differs in abundance of the small pustules preferential in cortical substance containing a mycotic embolus in a gleam of arterioles or capillaries of balls.

In cups and a pelvis at purulent urinogenny P. the plethora of vessels, purulent infiltration of their walls, erosive and ulcer defects, dystrophy and desquamation of an epithelium, a limfangiita and phlebitis of subepithelial departments is observed (tsvetn. fig. 6). The purulent inflammation extends preferential on limf, and to venous collectors of a stroma of separate pyramids and to a lesser extent on a gleam of distal tubules and collective tubes.

At difficulty of outflow on ureters develops pyonephrosis (see). The urothelium of a pelvis is exposed to flattening or in the form of thin tyazhy grows into the subject fabrics, quite often forming small epithelial cysts.

At acute P. with mesenchymal reaction against the background of subsiding of leukocytic infiltration increase of limfogistiotsitarny infiltration of the stroma which is gradually exposed to fibrosis is noted.

Chronic P. differs in the polymorphism of changes reflecting character and duration of inflammatory process. Its specific features are the ochagovost and asymmetry of defeat.

Macroscopically the type of kidneys at far come process is characterized by reduction of their weight, uneven narrowing of cortical substance therefore on the surface of kidneys platoobrazny retractions are formed.

Microscopically at a granular kidney along with extensive fields of fibrosis with full destruction of tubules and a hyalinosis of balls, and also massive diffusion and focal limfogistiotsitarny infiltration with impurity of plasmocytes considerable sites concerning the kept parenchyma are noted. At a recurrence of an inflammation among cellular infiltrate impurity of polymorphonuclear leukocytes is always found. The stroma in these sites is edematous and rich with acid glikozaminoglikana, macrophages about CHIC - hollow zhitelnymi inclusions in cytoplasm meet here. Electronic microscopically in them the set of the lysosomes containing the destroyed cellular organellas is found.

The progressing fibrosis and a hyalinosis of intersticial fabric with formation of randomly located large cicatricial fields different from uniform fibrosis at an arteriolo-nephrosclerosis and a glomerulonephritis is observed. Growth of connecting fabric and massive inflammatory infiltration are followed by obstruction of distal tubules and expansion of proximal departments of nephron — nefrogidrozy. The epithelium of such tubules atrophies, in their gleam eosinophilic kolloidopodobny masses collects that gives to a renal parenchyma microscopically a type of a thyroid gland (a so-called tireoidization of tubules). Though the tireoidization of tubules meets most often at hron. The item, it, as well as limfogistiotsitarny infiltration of a stroma, is not its specific feature and is observed at some other patol, processes, napr, at hron, a glomerulonephritis, a heavy arterioarte-riolonefroskleroz, an amyloidosis, extensive heart attacks of kidneys, etc. Final diagnosis hron. The item is put on the basis a wedge, and patomorfol. data.

In interlobular and arc arteries, and also arterioles the thickening and a sclerosis of walls with a hyperplasia of an internal cover is quite often observed. The focal thickening of a basal membrane of capillaries of balls, expansion of a mesangium, synechia of separate capillary loops, a proteinaceous exudate in a gleam of capsules are almost always noted that is considered as a reactive or secondary glomerulitis. Changes of arteries and balls happen especially widespread at P. which is followed by arterial hypertension.

The sizes and depth of damage of kidneys at hron. Items can be different. T. I. Ganzen (1974) allocates the following morfol, forms: hron. The item with the minimum changes, with a stromal and cellular component, with a tubulostromalny component, with a stromal and vascular component, the mixed form and hron. The item from the outcome in wrinkling of kidneys.

Acute pyelonephritis

Acute P. can arise at various age, but meets in 20 — 40 years more often. At P. women in most cases has the urinogenny (ascending) character, being a complication acute cystitis (see). At men the disease most often arises gematogenno. Both kidneys are surprised with an identical frequency; usually in several days, sometimes weeks, after a sformirovaniye in an organism of primary suppurative focus.

The clinical picture

the Clinical picture depends on extensiveness and a form of defeat of tissue of kidney, virulence of contagiums, age of the patient, a state it immunol, reactivity.

At patients body temperature usually increases, pains of the aching character in lumbar area develop. After several hours of fever temperature usually critically decreases that is followed by plentiful sweating, but later a nek-swarm time or next day, is frequent at the same time days, the attack of fever renews and has gektichesky or intermittent character. Pains become aggravated at disturbance of passability of uric ways and irradiate to the suprapubic area, a crotch, a hip, external genitals. The painful speeded-up urination can be observed. At conjoined manipulation often define increase in the sizes of a kidney. Muscles of lumbar area are strained, Pasternatsky's symptom positive (see. Pasternatsky symptom ). At a number of patients the rachiocampsis towards the affected kidney is noted. Symptoms of irritation of a peritoneum appear during the formation of abscess on a front surface of a kidney. The spastic contracture of lumbar muscles with forced bending of a leg in coxofemoral and knee joints (so-called psoas-eimpty) demonstrates development of a paranephritis (see) on a back surface of a kidney.

Most persistently the secondary P. interfaced to disturbances of urodynamic proceeds. At the beginning of a disease the febricula, a headache are often observed. Then there are a tremendous fever, cyanosis of skin and quickly temperature to 39 — 40 ° and more increases. Symptoms of intoxication — nausea, vomiting, short wind, tachycardia, a black-out are expressed. The picture of the bacterial shock which is result of impact of microbic endotoxins on cardiovascular system and characterized by sharp pallor, emergence of cold sweat, falling of the ABP, a loss of consciousness is quite often observed. During the falling of systolic pressure below 80 — 60 mm of mercury. the oliguria, an anury, i.e. symptoms of an acute renal failure are noted (see). Acute P. is burdened by bacterial shock more often at patients with a diabetes mellitus, at persons with the hidden abnormal liver functions. It can arise at a gram-negative infection, is frequent as manifestation hospitalism (see) later diagnostic and to lay down. manipulations; at such «iatrogenic» acute P. emergence of signs is especially dangerous hepato-renal syndrome (see): jaundices, bilirubinemias, increases in a liver. At a latent current of acute P. the general and local symptoms are a little expressed.

The diagnosis

the Diagnosis at acute P. is based on data a wedge, pictures, laboratory and tool researches. At a laboratory research the leukocytosis, a deviation to the left, acceleration of ROE, decrease albumine-globulinovogo of coefficient, a hypergammaglobulinemia, quickly progressing anemia is found. Sometimes anemia masks increase in a hematocrit in connection with dehydration. In urine the most constant sign is the leukocyturia (see) though at the beginning of a disease it can be absent or be insignificant. In such cases the quantitative research of an urocheras on Kakovsky's method — Addis, Ambyurzhe or Nechiporenko is shown (see. Kakovsky — Addis a method ), definition of so-called cells Stern - the gamer — Malbin (the leukocytes possessing special characteristics of coloring and Brownian motion of granules of cytoplasm) and active leukocytes. A characteristic symptom of acute purulent P. is existence in an urocheras of leukocytic cylinders. Destruction of renal nipples can be followed by expressed hamaturia (see).

The item often precedes and accompanies bacteriuria (see), degree it can reach 105 and more bacteria in 1 ml of urine. The bacteriuria is absent only at impassability of an ureter or formation of the closed (not emptied) abscess in a parenchyma of a kidney. However the bacteriuria is not equivalent

P. V of blood activity of a lactate dehydrogenase, transaminase, leucineaminopeptidase, an alkaline phosphatase amplifies, the general proteolytic activity, level of inhibitor of trypsin increase. In urine tripsinopodobny activity increases. Increase in blood of level of residual nitrogen, urea, creatinine indicates bilateral damage of kidneys.

At a heavy current of P., especially at absence or a small leukocyturia, and also instructions on the previous cystitis, it is necessary to investigate a rachiocampsis, upper uric ways. For this purpose make a survey X-ray analysis, excretory urography (see), ultrasonic scanning, a radio isotope renografiya (see Renografiya radio isotope), a hromotsistoskopiya (see). The survey X-ray analysis allows to define situation and the sizes of kidneys, to reveal shadows of X-ray contrast stones in projections of uric ways, an illegibility of a contour of a big lumbar muscle and a shadow of a kidney. The excretory urography reveals increase in the sizes and intensity of a shadow of a kidney, restriction of its shift at breath, a delay or lack of filling with a contrast agent of upper uric ways. At moderate disturbances of urodynamic expansion of upper uric ways above the place of an obstacle to outflow of urine is characteristic. Urokinema-tografiya, roentgenoscopy allow to reveal dyskinesia of cups. Infiltrative changes of a renal parenchyma lead to the shift of cups, a prelum and lengthening of their necks, protrusion of an outside contour of a kidney.

Fig. 1. A bilateral retrograde ureteropiyelogramma at left-side purulent pyelonephritis (the picture is made with two exposures — on a breath and an exhalation): on the right two shadows of a pelvis and cups reflecting their situation in an exhalation (1) and a breath (2), at the left — one shadow (restriction of mobility of a kidney) are visible.

Suppurative focuses in an upper pole of a kidney lead to restriction of mobility of a diaphragm, emergence of an exudate in a pleural cavity, to sharp restriction of mobility of the affected kidney (fig. 1).

At a hromotsistoskopiya passability of uric ways is defined, and on decrease in intensity of coloring of the urine emitted by the affected kidney it is possible to estimate extent of disturbance of its function. Lack of release of urine from the mouth of an ureter serves as the indication for diagnostic and to lay down. catheterizations of upper uric ways (see. Catheterization of uric ways ). Release of purulent urine on a catheter under pressure testifies to the expressed urinary stasis. Executed then the piyelouroterografiya pokhmogat to specify character and extent of damage of a kidney, to determine the level and the reason of occlusion of uric ways. In this case it is necessary to make drainage of uric ways (see. Drainage ).

Radio-gramophones, researches at acute serous P. reveal minor changes of Renault - and skanogramm. Deeper defeats of a parenchyma are followed by delay and decrease in accumulation, increase in an elimination half-life of radionuclide.

At an urinary stasis the curve renogram-we has the ascending direction. On skanogramma at a dynamic stsintigrafiya defects of accumulation of radionuclide according to the centers of an inflammation, kidneys, especially extensive at an anthrax, are visible. The radio isotope tsistorenografiya, a miktsionny tsistouretrografiya (a research during an urination) allow to reveal a puzyrnomochetochnikovy reflux.

Differential diagnosis. Acute P. needs to be differentiated with a necrosis of renal nipples (see. Renal nipples necrosis ), at Krom the otkhozhdeniye with urine of the sequestered nipples or their fragments, more intensive and constant hamaturia is observed. Destruction of a nipple is found on piyelogramma in the form of defect of the filling of a cup corresponding in a form to the sequester, penetration of X-ray contrast solution into marrow of a kidney in the form of a ring-shaped shadow, the roughness of a contour of a nipple reminding, but to Yu. A. Pytel's definition, a flame of a fire.

Symptoms, similar to acute P., are found in patients pyonephrosis (see) at occlusion of an ureter and at infection hydronephrosis (see).

Paranephritis (see), the accompanying P. or which independently arose differs in tension of lumbar muscles, pains, the fever which is not giving in to antibacterial therapy. At excretory Urografinum the smoothness of a contour of a big lumbar muscle, a displacement of the kidney are noted. Make a puncture of retroperitoneal space for specification of the diagnosis.

Treatment

At acute P. the bed rest, plentiful drink are necessary (cranberry drink since it contains a large amount of the sodium benzoate is useful). At the expressed dehydration intravenous administration of isotonic solution of sodium chloride, Polyglucinum, 20% of solution of glucose is shown. Apply 3 — 4% to elimination of acidosis solution of a gpdrokarbonat of sodium.

The most important element of treatment of P. is rationally constructed antibacterial therapy. At serous P. appoint hexamethylenetetramine (urotropin) in the form of 40% of solution or mixture in combination with streptocides (Sulfapyridazinum, sulfadimethoxine, sulfalene, Etazolum). At P. caused by gram-negative flora apply antiseptic agents (furadonin, furagin, furasolidone, Nevigramonum, etc.).

At intoxication high doses of antibiotics of a broad spectrum of activity are shown (ampicillin, Oxacillinum, levomycetinum, streptomycin, erythromycin, Kanamycinum, gentamycin, rifampicin, tseporin, tetracycline, Metacycline, lincomycin, Morphocyclinum).

Combinations of antibacterial agents, napr are reasonable, antibiotics with streptocides, nitrofurans, etc. Due to a possibility of resistance of microflora to antibacterial agents it is necessary to change them each 5 — 7 days. At severe forms of P. of a dose of antibiotics shall be maximum. At dysfunction went. - kish. path preferably parenteral administration of drugs. Duration of antibacterial therapy and possibility candidiasis (see) do necessary purpose of antifungal means (levorinum, nystatin). For increase in resistance of an organism to an infection enter immune plasm, gamma-globulin, interferon, staphylococcal anatoksinony

At bacterial shock apply in high doses a hydrocortisone (to 1000 mg a day), Prednisolonum, antihistaminic drugs (Dimedrol, Suprastinum, Pipolphenum), strict correction of disturbances of water and electrolytic balance, acidosis is necessary, intravenous administration of antibiotics is shown. Sometimes use inhibitors of proteolysis (Trasylolum, Gordoxum).

At occlusal disturbances of urodynamic urgent catheterization of upper uric ways allows to eliminate an obstacle to outflow of urine and to stop the phenomena of bacterial shock. The urgent litoekstrak-tion with the subsequent drainage of upper uric ways is in some cases necessary. If disturbances of urodynamic in such a way do not manage to be eliminated, urgent operation — decapsulations of a kidney (see), a pyelostomy (see) or a nephrostomy is necessary (see). The anthrax, large abscesses of a kidney open and delete necrotic the changed fabrics. At the isolated anthrax in one of poles it is reasonable to excise it or to make a nephrectomy. At a multiple anthrax or abscesses of a kidney with the phenomena of an urosepsis (see. Sepsis ) the nephrectomy is shown (see), especially at fungal infections of a kidney.

Forecast depends on extent of damage of a kidney and the general condition of the patient. At the purulent forms of acute P. demanding operational treatment, the lethality reaches 20%. Gets from 45% of sick P. hron, a current. Resistance of the activator to antibacterial agents, an otgranicheniye of the inflammatory center in a kidney, permanent disturbance of urodynamic, decrease in protective forces of an organism are cicatricial fabric the reasons of it. Working capacity at the persons who transferred P. usually remains, only 12% of patients, by data A. Ya. Pytelya, are forced to pass to easier work.

Prevention: a timely intensive care of pyoinflammatory processes in an organism from where the infection can get into a kidney; a careful asepsis and antiseptics at prove-



deniya of tool researches of urinogenital system, especially in the presence of an urinary stasis; the acute effective management at renal colic since disturbances uro-and a hemodynamics at it contribute to flash inf. process in a kidney.

Fig. 2. The survey roentgenogram of an abdominal cavity and a basin at emphysematous pyelonephritis: in a projection of a right kidney multiple gas bubbles of irregular shape are visible (are specified by shooters).

Emphysematous pyelonephritis — one of forms acute purulent P. Nablyudayetsya is preferential at patients with a diabetes mellitus, is slightly more often at women. Activators are colibacillus, V. aerogenes, proteas, staphylococcus, etc. Emphysematous P.'s emergence is promoted by existence in an organism of anaerobic microorganisms, obstruction of uric ways. The disease usually affects one kidney and is quite often combined with a necrosis of renal nipples, thrombosis of a renal vein. The necrosis of a parenchyma of a kidney with formation of gas in body and in pararenal cellulose is characteristic. High content of glucose in blood at a diabetes mellitus is the accessory factor causing production of carbon dioxide gas. The disease proceeds hard, is followed by the state reminding a stupor, intoxication, a renal failure, high temperature, severe pains in lumbar area, a leukocytosis, a leukocyturia, a bacteriuria. Urine has sharply acid reaction. In emphysematous P.'s recognition the large role is played rentgenol, by methods of a research, in particular a survey picture, a computer tomography. On the roentgenogram in a projection of a kidney accumulation of shadows of gas bubbles (fig. 2) is visible. At bacterial, a research of urine find gas-forming microorganisms.

Treatment operational. Make more often nephrectomy (see). At the same time carry out antiinflammatory and disintoxication therapy (see), treatment of a diabetes mellitus (see. diabetes mellitus ). According to Karris and Schmidt (S. K. of Garris, J. D. Schmidt, 1977), the lethality at conservative therapy makes 75%, at operational treatment — 23%.

Chronic pyelonephritis

Hron. The item is found preferential at young and middle age, in women by 2 — 3 times more often than at men. Acute P.'s transition to chronic is established in the presence at the patient of symptoms of a disease for 3 months and more. It is more difficult to judge an onset of the illness at primary hron. P. Atipichnost, small expressiveness of many clinical signs often complicate timely recognition of a disease.

Clinical picture and current

Symptomatology hron. The item varies depending on a form, disease, activity and localization of process (one - or bilateral).

Usual complaints: a febricula, increased fatigue, pain in lumbar area, headaches, periodically arising phenomena of cystitis.

Pallor, pastosity of the person, morbidity at a palpation of kidneys are in most cases observed, a positive symptom of Pasternatsky, pain in epigastric area, arterial hypertension, subfebrile temperature.

Depending on a wedge, symptoms and data of inspection allocate a number of forms hron. P.

The wavy form is characterized by changes of phases of active, latent inflammatory process and remission. In a phase of an active inflammation the subfebrile temperature, the expressed leukocyturia, a bacteriuria, existence of active leukocytes in urine, acceleration of ROE are noted. In a latent phase the standard temperature, a leukocyturia and a bacteriuria are expressed slightly or clearly are defined only at provocative tests (see). Active leukocytes in urine are found in smaller quantity, than at acute P., or at all are absent. In blood there are no changes. The phase of remission is characterized by rather good health of patients, normal analysis findings of blood and urine.

Primary latent form proceeds in the absence of typical symptoms of a disease. The indisposition, a headache, subfebrile temperature can be observed. Periodically, more often by means of provocative tests, in an urocheras the moderate leukocyturia, a bacteriuria and active leukocytes are found.

The Gematurichesky form is characterized by the repeating attacks of a macroscopic and resistant microscopic hamaturia. The disease is usually connected with the venous hypertensia creating premises to disturbance of an integrity of vessels of a fornikalny zone of a kidney. Rentgeno-and radiological inspection, except P.'s signs, finds a nephroptosis in such patients (see), pedunkulit (see).

The calculous form arises because pyoinflammatory damage of kidneys and upper uric ways is complicated by a secondary nephrolithiasis (see the Nephrolithiasis). The disease is followed by pains in lumbar area, attacks of renal colic, a resistant microscopic hamaturia, an otkhozhdeniye urinary stones (see). Primary character of P. is confirmed by the fact that symptoms of inflammatory damage of a kidney are found before formation of a concrement in it.

The tubular form sometimes is the leader in a wedge, manifestations hron. P. Owing to defeat of tubules there are unindemnifiable losses with urine of sodium and potassium, acidosis develops (see). Permanent decrease in total quantity of sodium conducts to a hyponatremia? hypovolemia, hypotensions, to falling of glomerular filtering. Latentno the proceeding tubular form at P.'s aggravation or other disease can suddenly be shown by symptoms of an acute renal failure (see).

The anemic form is connected with loss by a kidney of ability to products of eritroioetin. Persistent hypochromia anemia sometimes is the most expressed sign is hidden the proceeding Item.

Rare forms: hron. The item proceeds with dominance of symptoms of a disease went. - kish. a path (an enterorenalny form) or with the dysfunction of adrenal glands which is shown a picture of an addisonizm (see. Addisonova disease ).

The diagnosis

For reliability of the diagnosis needs to be established at the patient not less than five characteristic signs of P. (the pyuria, a bacteriuria corresponding funkts, the disturbances of kidneys corresponding rentgeno-and the radiological changes given to a biopsy of kidneys). About a half of patients indicates the postponed acute P. or existence in the past of the signs characteristic of this disease. In the analysis of urine by Kakovsky's method — Addis, Ambyurzhe or Nechiporenko are determined a leukocyturia) that is facilitated by use of pe-rokeidazny coloring. Special value has qualitative analysis of a leukocyturia, identification in an urocheras of cells of Shterngaymer — Malbina and active leukocytes.

At doubtful indicators of a leukocyturia specification by means of provocative tests is necessary. Among them the most widespread is the prednizolonovy test. Increase in intensity of a leukocyturia more than for 100%, emergence of active leukocytes, increase of degree of a bacteriuria in tests of urine in 1 — 3 hour after intravenous administration of 30 — 40 mg of pre-Nisolonum-phosphate is characteristic of latent P. U of such patients after administration of Prednisolonum number of leukocytes in the blood taken from skin of lumbar area can more than for 20% to exceed quantity of leukocytes in the blood received from a finger. Leukocyturias) at patients latent 11. it is possible to provoke administration of pyrogenal, radiopaque substances, some antianemic means, forcing of a diuresis.

Nek-ry urologists consider the major for diagnosis hron. The item identification of a true bacteriuria — high microbic number (105 and above) in the urine received from an average portion during an urination or by means of a suprapubic puncture of a bladder. At the same time for approximate quantitative researches of a bacteriuria usually use trife-niltetrazoliykhloridny or nitrite tests, method of submersible plates or glyukozospetsifichesky paper test; — make crops on firm environments for more exact. However not in all cases hron. The item is found a true bacteriuria, and existence it does not say that process is localized in upper uric ways.

At hron. The item is noted a leukocytosis with a deviation to the left, acceleration ROE, anemia, the phenomena anizo-, a poikilocytosis. The disproteinemia is characteristic. On an aggravation hron. The item can specify emergence of S-reactive protein, increase in maintenance of a lactate dehydrogenase, succinatedehydrogenase, increase in the general proteolytic activity of plasma.

The expressed disturbances of a homeostasis arise at a bilateral hron. The item burdened by a renal failure (see). The research of function of kidneys before everything finds decline in the ability them adequately to react to loadings ammonium chloride, sodium bicarbonate, falling of the maximum canalicular secretion. Further coefficients of renal clarification on creatinine, urea decrease, the phenomena of acidosis accrue, the azotemia appears, osmolarity of urine respectively decreases, the maximum density is established lower than 1, 028 at concentration test on Folgarda (see Kidneys, methods of a research). Zimnitsky's test (see. Zimnitsky test ) reveals nocturia (see), hypo - or an isosthenuria (see).

Immunol, researches (a blastogenic response and migrations of leukocytes, content of immunoglobulins, etc.) at many patients hron. Items find decrease in protective forces of an organism. Increase in a caption of specific antibodies to one of the species of microorganisms allocated from sick P.'s urine allows to consider it a disease-producing factor and to estimate a degree of activity of inflammatory process.

Establishment with the help tsistoskopiya (see) inflammatory changes around the mouth of an ureter, delay or lack of release of indigo carmine at a hromotsistoskopiya helps to establish what kidney and respectively upper uric ways are affected.

The leading value in recognition hron. Items have methods rentgenol. researches. At survey urography (see) reduction of the sizes and consolidation of a shadow of the affected kidney can be noted. It comes to light at excretory, especially infusional, urography more clearly. Reduction of length of one of kidneys more than on 1 cm, high, vertical position of body are suspicious concerning a nephrosclerosis, a perinephritis. Functional and organic changes of upper uric ways are shown by existence of resistant spasms and narrowings of necks of cups, an atrophy of renal nipples owing to what cups get a fungoid, kolbovidny form. Emergence of fresh inflammatory infiltrate leads to a prelum and drawing apart cups. In a zone of a nephrosclerosis there is a rapprochement of cups and lengthening of their necks. Irregularity of defeat of a parenchyma of a kidney at hron. The item is often expressed in emergence of the characteristic symptom described by Hodson (Page G. Hodson): on Urogramum of a normal kidney the line drawn through tops of all renal nipples passes parallel to an outside contour of a shadow of a kidney; at hron. Items nek-ry cups owing to a nephrosclerosis come to lateral edge of a kidney, others are displaced by hems towards a pelvis. Thus, the line connecting tops of nipples becomes wavy and is not parallel to an outside contour of a kidney. A pelvis of a kidney at hron. The item it is often expanded, the atonichna, because of it on its medial surface is found a print of the outer edge of a big lumbar muscle (a regional psoas symptome). Extent of reduction of volume of a renal parenchyma and dilatation of lokhanochnochashechny system can be more precisely defined during the calculation of Renault - a cortical index (private from division of the work of length of a lokhanochno-cup shadow and its width into the work of length and width of a shadow of all kidney); normal it is equal to 0,38 — 0,4. For hron. Items are characteristic higher values.

At renal arteriography (see. A renal angiography) find reduction of caliber of the main trunk of a renal artery in comparison with an artery of other party. At the beginning of a disease the obliteration of small vessels of cortical substance of a kidney, later — larger vessels is observed that gives to the angiogram a species of a burned tree. In a nefrografichesky phase of a research change of a form and the sizes of the affected kidney in comparison with healthy clearly is visible.

Rentgenol, researches allow to establish also inherent hron. Item of change of an ureter: owing to a pedunkulit it is narrowed in prilokhanochny department, on other extent is expanded, gipoto-nichen.

At a radio isotope renografiya the most constant symptom is delay of an elimination half-life of radionuclide from the affected kidney. The progressing granular kidney is followed by decrease in secretory, and then and vascular segments of a renogramma. Radio isotope scanning of kidneys in connection with loss by the sclerosed sites of a kidney of ability to accumulate radio pharmaceutical drug allows to gain an impression about extent of preferential localization nephrosclerosis (see). These symptoms come to light by means of dynamic even more clearly stsintigrafiya (see). Radio isotope renal angiography (see) gives the qualitative and quantitative characteristic of blood supply of each kidney. For this purpose it is possible to use also renal reografiya. Data on the sizes, an arrangement and a shape of kidneys at sick P. can be received also by means of ultrasonic scanning (see. Ultrasonic diagnosis ), a computer tomography (see. Tomography computer ).

Diagnosis hron. The item can be confirmed by means of a puncture biopsy of a kidney. Morfol, signs hron. The item, according to A. M. Vikhert with sotr. (1980), the following changes are: a focal and intersticial sclerosis with infiltration by lymphoid and histiocytic elements, neutrophils; an atrophy of an epithelium of tubules in a zone of an intersticial sclerosis with expansion of their gleam and filling with the condensed kolloidopodobny masses — a so-called tireoidization of tubules; periglome-rulyarny ekstrakapsulyarny sclerosis, internal edema of a ball (glomerulogidroz); grouping to 10 — 15 balls in one field of vision of small increase in a microscope; a productive endarteritis and a perivascular sclerosis with deformation of a wall and gleam of a vessel. At patients with high arterial hypertension the hypertrophy, a hyperplasia of the juxtaglomerular device with hyper granulation of epithelial cells often comes to light. Due to the ochagovost of damage of kidneys separate morfol, signs can be absent that does not allow to exclude nevertheless the diagnosis hron. The item also dictates need of further observation and repeated inspection of patients.

Differential diagnosis.

Hron. The item most often should be differentiated with a nephrophthisis (see Tuberculosis extra-pulmonary), a glomerulonephritis (see), an idiopathic hypertensia (see), and also similar changes of kidneys at collagenoses, a sugar diaoyet, gout (distinctiveness of these zabolevashsh the fact that they are followed by symmetric damage of kidneys whereas hron is. The item is or unilateral process, or asymmetrically affects the right and left kidneys). At a nephrophthisis unlike hron. Items destructive changes prevail over sclerous that is established radiological. Tsistoskopiya allows to find a characteristic picture of tubercular cystitis, and from crops of urine mycobacteria of tuberculosis can be allocated.

An atony and dilatation of a pelvis at hron. The item it is similar, according to a piyelografiya, to an initial stage of a hydronephrosis (see). It is possible to distinguish them at identification in urine of patients hron. Item of the hidden bacteriuria and pyuria.

By means of radio isotope Renault-grafii against the background of an artificial diuresis at patients with a hydronephrosis establish deterioration in outflow of urine in comparison with the previous data; at hron. Time of semi-removal of radionuclide is often extended with the item.

Treatment

Treatment shall be based on elimination of causes of illness: sanitation of probable sources of spread of an infection in an organism, operational correction of disturbances of urodynamic, increase in protective forces of an organism. Rationally constructed antibacterial therapy on the basis of data bacterial, researches of urine and an antibiotikogramma is necessary. At first appoint drug, more efficient concerning the activator, preferably an antiseptic agent (nitrofurans, 5-HOK, Nevigramonum, nitroxoline, streptocides). From antibiotics it is reasonable to apply the means having the minimum nephrotoxic influence (semi-synthetic Penicillin, levomycetinum, erythromycin, gentamycin, tseporin). Antibacterial therapy shall continue continuously not less than 2 months with change of drugs each 7 — 10 days. At permanent disappearance of a leukocyturia and bacteriuria, active leukocytes in urine, normalization of blood tests can pass to use of discontinuous rates of antibacterial agents, at first bucketed into 1 — 2 week, and then more long. In a phase of remission carrying out preventive courses of antibacterial therapy and physiotherapeutic procedures for 2 — 4 weeks in autumn and spring time is justified. Efficiency of antibacterial treatment increases at observance of the diet excluding hot dishes at increase in water loading, use of vegetable diuretics (renal tea, diuretic tea). For the purpose of activation of immunity apply Prodigiosanum, the autovaccine made of the microbic culture received at crops of urine.

Dignity. - hens. treatment is recommended in the resorts of Truskavets, Zheleznovodsk.

At heavy patients with an end-stage hron, a renal failure according to special indications carry out a hemodialysis (see), haemo filtering (see), peritoneal dialysis (see), renal transplantation (see).

The forecast and Prevention

the Forecast is more favorable at early diagnosis and timely treatment of a disease. At far come anatomo-functional changes of a parenchyma of a kidney and uric ways it worsens. Timely intensive long care reduces the frequency of a recurrence of a disease and prolongs life to patients for many years. Permanent remission manages to be reached in 50% of cases.

Prevention: adequate treatment of acute P.; elimination of the centers of an infection in an organism, especially diseases of urinogenital system (cystitis, prostatitis, an epididymite, etc.); timely correction of disturbances of urodynamic at an urolithiasis, adenoma of a prostate is important.

The complicated forms of chronic pyelonephritis

Ksantogranulematozny pyelonephritis occurs both at adults, and at (preferential female) children. Many researchers believe that ksantogranulematozny P. results from prolonged treatment of purulent P. antibiotics that leads to change of properties of microorganisms, disturbance of metabolism of lipids, phlebitis of intra renal veins. At ksantogranulematozny P. there is a destruction of tissue of kidney to release of lipoid substance. An infestant is most often proteas, colibacillus, golden staphylococcus, the mixed flora is more rare. The disease arises preferential at obturation of an ureter and affects one kidney diffuzno or its separate segments. In a parenchyma of a kidney there is a growth of the granulyatsionny fabric containing a large amount of the fat giving it yellow-brown, golden color. The kidney is increased, hilly, shrouded in the sclerosed cellulose which is often containing accumulations of pus. Find lamellar accumulations of granulematozny foamy cells in a parenchyma — the histiocytes containing lipids, lymphocytic infiltrates.

Patients are disturbed by back pains and hypochondrium, temperature increases. The kidney is usually increased and is well probed in the form of tumorous education. Arterial hypertension, a leukocytosis, a leukocyturia, a proteinuria is often noted. At a survey X-ray analysis in a kidney quite often find concrements, at excretory Urografinum — a picture of «a mute kidney». Presurgical diagnosis of ksantogranulematozny P. is possible by means of arteriography, however the final diagnosis is established during an operative measure according to a biopsy. The nephrectomy is shown at diffusion damage of a kidney. In an early stage of a disease excision a xanthogranuloma-toznykh of nodes or a nephrectomy can be made. The forecast at most of patients after operation favorable.

Hypertensive form. Arterial hypertension is observed on average at 32% of patients hron. P. Its malignant current is noted in 10% of cases. This form P. meets at young age at female persons more often. Among children girls suffer from a hypertensive form P. also preferential.

Inflammatory process in intersticial tissue of a kidney with an angiosclerosis and considerable disturbance of blood circulation of body is the main reason for developing of hypertensia at P. The granular kidney most quickly comes at broken venous and limf, outflow that takes place at the pedunkulit which is often complicating P. Sistema a renin — angiotensin — Aldosteronum, according to H. Sarre and sotr. (1971), Linder (F. Linder, 1972), etc., at P. can not take part in genesis of hypertensia. It is possible that high the ABP at hron. The item depends on loss by a kidney of ability to produce so-called hypotensive substance.

Arterial hypertension can arise also at the beginning of P.; in such cases, according to Yu. A. Pytel I (1978), it has the central neurohumoral genesis, turning on of renal and other pressor mechanisms happens in the subsequent.

A wedge, manifestations — long headaches, anemia, thirst, a polyuria, sometimes subfebrile temperature, decrease in working capacity.

Fig. 3. A left-side retrograde ureteropiyelogramma at a hypertensive form of chronic pyelonephritis: deformation of cups, flattening and atrophy of nipples (1), deformation of a pelvis (2), narrowing and straightening of an ureter (3).
Fig. 4. The selection arteriogramma of a right kidney at a hypertensive form of chronic pyelonephritis: in the lower pole of a kidney an obednennost of the vascular drawing and amputation of separate large branches of a renal artery (it is specified by shooters).

The Radirizotopny renografiya, reografiya, renal angiography are the most valuable diagnostic methods allowing to establish P.'s presence and localization of defeat (fig. 3, 4).

Conservative treatment is ineffective. The nephrectomy or a nephrectomy, especially in early stages of unilateral P., lead at most of patients to recovery; hypertensia, according to V. S. Gagarinov and I. S. Kamyshan (1973), A. Ya. Pytelya (1977), disappears after a nephrectomy on average at 70% operated. At the arterial hypertension caused bilateral hron. Items, sometimes resort to operation of an enterorevas-kulyarization of a kidney, to renal transplantation.

Pyelonephritis at pregnant women

P.'s Frequency at pregnant women fluctuates within 2 — 10%, and it can arise at women in labor and women in childbirth, i.e. throughout all so-called gestational period. Nek-ry clinical physicians use the term «gestational pyelonephritis», allocating its separate forms: Item of pregnant women, P. of women in labor and P. of women in childbirth.

Gestational P. has the patterns of development and feature of a current. Activators P. at pregnant women — colibacillus, Klebsiella, proteas; at women in childbirth — enterokokk, colibacillus. In gestational P.'s pathogeny the big role belongs fiziol, to the hormonal shifts arising in an organism of pregnant women and the given rise women. Qualitative and quantitative changes of composition of various hormones (estrogen, progesterone, a hydrocortisone, etc.), change of the anatomic relations at pregnancy contribute to disturbance uro-and a hemodynamics of upper uric ways, promotes infection of tissue of kidney and emergence of inflammatory process, especially iipn existence in an organism of the woman any inf. center.

Right-hand P. is most often observed that depends not only on a prelum of an ureter a pregnant uterus, but also on features of the right ovarian vein (expansion, its varicose change). More often women at the first pregnancy get sick. It is explained by insufficient adaptation of an organism to the changes happening at pregnancy (hormonal, immunological). At most of women of P. arises at the end of II — the beginning of the III trimester of pregnancy (20 — 26 weeks and 32 — 34 weeks) when most hormonal ratios considerably change. The item at women in childbirth is more often shown on 4 — the 6th and 12 — the 14th day after the delivery, i.e. during those periods when there are puerperal complications — metrothrombophlebitis (see), metroendometritis (see), etc.

Klin, a picture P. in various durations of gestation has the features depending on extent of disturbance of a passage of urine on upper uric ways: in the I trimester the expressed pains in lumbar area are observed; in II, III trimesters of pregnancy at P. at women in childbirth of pain not intensive. Acute P. usually has no significant effect on the course of pregnancy (see); at chronic — it is quite often observed not incubation of pregnancy (see), premature births (see), toxicoses of pregnant women (see). At acute P. childbirth proceeds spontaneously and does not demand special manipulations; at hron. The item in 10% of cases it is necessary to resort to artificial early rodo-excitement. Cesarean section (see) at P. at pregnant women it is admissible according to strict obstetric indications, at the same time preference should be given to an ekstraperitonealny method.

In gestational P.'s diagnosis the great value belongs to data of laboratory methods (a leukocytosis, neutrophylic shift of a formula to the left, moderate hypochromia anemia, a leukocyturia, a bacteriuria). Definition of extent of disturbance of a passage of urine from upper uric ways is reached by means of a hromotsistoskopiya. Untimely release of indigo carmine in II and III trimesters of pregnancy at a wedge, a picture P. is the indication to catheterization of ureters on purpose not only recovery of a passage of urine, but also prevention of bacterial shock. Rentgenol, inspection of women throughout all pregnancy is undesirable because of possible harmful effects on a fruit. The research of kidneys at pregnant women is made by method of ultrasonic scanning (see. Ultrasonic diagnosis).

Gestational P.'s treatment shall be P., complex, individual taking into account features of a current, at pregnant women and women in childbirth. In order to avoid harmful effects on a fruit in the I trimester of pregnancy apply only natural and semi-synthetic Penicillin (ampicillin, karbenitsillin, etc.). In II and III trimesters of pregnancy, except the listed penicillin, appoint antibiotics of group of aminoglycosides (gentamycin, Kanamycinum), cephalosporins, Makrolida (erythromycin), lincomycin. Throughout all pregnancy use of antibiotics tetracycline, left-mitsetinovogo ranks and streptomycin because of an adverse effect on a fruit is contraindicated. In II and III trimesters of pregnancy along with antibiotics other antiinflammatory drugs are used (furagin, 5-HOK, Nevigramonum, Urosulfanum). P.'s treatment at women in childbirth is carried out taking into account possible influence of pharmaceuticals through milk of mother on the newborn. In addition to the specified therapy, to pregnant women and women in childbirth appoint low-toxic diuretics (Uregitum, furosemide). Completion of proteinaceous balance is reached by a transfusion of albumine, a plazkhma, blood; for desintoxication enter low-molecular solutions (Haemodesum, reopoliglyukin). Success of treatment in many respects depends on timely recovery of the broken passage of urine that is reached by bilateral catheterization of ureters, to-ruyu make in the fever patient at lack at them of effect of the carried-out antibacterial therapy within a day or not receiving any treatment. In the absence of effect of catheterization of ureters and antibacterial therapy within 2 — 3 days (gektichesky fever, a fever) operation is shown — decapsulation of a kidney (see) opening of suppurative focuses, imposing of a nefrostoma (see. Nephrostomy ). Inflammatory process in a kidney quite often continues after the termination of a puerperal period, in this regard further overseeing by these patients of the urologist is required.

The forecast at the timely diagnosis and early rational therapy favorable. At the heavy course of process and inefficiency of treatment adverse effects — transition in hron are possible. Item, emergence of a hypertensive form P., etc.

Gestational P.'s prevention consists in identification in clinic for women at nonpregnant women of diseases of uric ways and their timely treatment. Existence of a leukocyturia, bacteriuria demands the corresponding treatment from pregnant women, in the absence of effect hospitalization in a specialized hospital is necessary.

Pyelonephritis at children

In P.'s pediatrics can be considered as the microbic and inflammatory defeat of tubules, intersticial tissue, pyelocaliceal system of kidneys which is clinically shown as inf. a disease, especially at children of early age of newborns, leukocyturia (see), bacteriuria (see) and renal failure.

The major factors promoting P.'s emergence at children are uropathies of the inborn and acquired character, defiant disturbances of urodynamic. Uric refluxes and a dysplasia of a parenchyma of a kidney, metabolic and medicamentous a nephropathy, and also immunodeficiency, changes of hormonal regulation of functions of kidneys, primary and secondary tubulopatiya, a nephrolithiasis, mobility of kidneys with disturbance of urodynamic and microblood circulation, a vulvovaginitis, cystitis are of great importance.

Activators P. at children most often are colibacillus, proteas, a pyocyanic stick.

The main a wedge, P.'s manifestations at children — a dysuria, a grippopodobny syndrome, an abdominal pain, a waist, intoxication, dispeptic frustration, asthenic conditions of the child. In a wedge, a picture at newborns and children of the first 3 months of life symptoms of the general intoxication with dysfunction prevail went. - kish. path; children of preschool age have intoxication, pains and a dysuria; at school age intoxication is shown in the form of an adynamy. It is most expressed a wedge, a picture P. at children with disturbances of urodynamic.

On P.'s activity at children allocate three degrees. Activity of the I degree clinically is not shown; the disease comes to light accidentally during the carrying out laboratory researches during medical examination, at registration of the child in kindergarten, a day nursery etc. At activity of the II degree a wedge, displays of a disease can be absent, P. comes to light according to laboratory researches (a leukocytosis, a neutrocytosis with band shift, acceleration of ROE, positive reaction to C-reactive protein, etc.). The highest activity (the III degree) is characterized by symptoms of intoxication, a leukocytosis, a neutrocytosis with palochkoyadernsh shift, a leukocyturia, a bacteriuria, biochemical changes of blood and urine.

At children allocate (wavy) and latent current of the Item, acute, chronic with aggravations. Depending on activity and prescription of a disease there are three extents of disturbance and defeat of function of kidneys. The I extent of disturbance funkts, conditions of kidneys is characterized by a diz-ritmiya of canalicular system (the rhythm of removal with urine of electrolytes and various metabolites within a day is broken). According to Zimnitsky's test, come to light nocturia (see), the low specific weight of urine in evening and night hours. At dysfunction of a kidney of the II degree the homeostasis can be not changed, but at its disturbance are observed a metabolic acidosis (see), hyponatremia (see), hyperphosphaturia, hyperchloruria (see), gipernatriuriya. A final stage (the III degree) of renal failures is hron, renal failure (see).

The long current of P. is characterized by accession of an allergic component, and 10 years are aged more senior autoimmune reactions are possible.

Philosophy of treatment of P. at children shall include the following of an action: elimination of a microbic factor short rates of antibacterial drugs (ampicillin, levomycetinum, furagin, Biseptolum, etc.); impact on the fundamental pathogenetic units of process by antihistaminic and antiserotoninovy drugs, anticoagulants, diuretics; recovery of disturbances of a renal hemodynamics (Euphyllinum, themisal, infusion of an adonis, etc.); reduction of load of kidneys dietotherapy (restriction of animal protein); performing symptomatic therapy (hypotensive, corrective metabolic shifts of content of potassium, sodium, phosphorus, calcium, acids, the bases and other substances in blood and urine); increase in resilience of tissue of kidney to inf. to the beginning (pentoxyl, Dibazolum, anabolic hormones within 30 — 40 days); elimination of the reasons promoting emergence of II. at children (elimination of the hidden centers of an infection, treatment of anomalies of development of kidneys and uric ways). During the involvement in patol, process of a liver and bilious ways are shown cholagogue means. In cases of a repeated aggravation of P. antibacterial therapy is carried out by also short course. Treatment by drugs of a rezokhinovy row (e.g., delagil) within 6 — 12 months and more is shown to children with intersticial nephrite, deformation of pyelocaliceal system owing to autoimmune reorganization of an organism after sanitation of urine. In hard cases of P. proceeding with hron, a renal failure, especially at children with the inborn or acquired uropathy, are shown peritoneal dialysis (see), hemodialysis (see) and other ways of extrarenal clarification of blood, and sometimes and renal transplantation (see).

P.'s forecast at children usually favorable. Early the begun antibacterial therapy and elimination of the reasons contributing to P.'s development lead to recovery. The forecast at children at P. which is followed hron, a renal failure is more serious.

P.'s prevention at children shall include the account and inspection of families with high risk on diseases of kidneys and uric ways; medical examination of the children who were born from mothers with toxicoses of pregnancy; early roentgenourologic inspection of the children who were born from the mothers who had various diseases in the first half of pregnancy, and also accepting medicines, especially progesterone. Children in whom during prevention of rickets vitamin D found positive test of Sulkovich (high content of calcium) are threatened on development to P. The risk of development of P. in children from families which members have disbolism which are characterized by a calciuria, an oksalaturiya, an uraturia and removal with urine of other nefrotoksichny substances is high. A preventive action in these cases is correction of the revealed disturbances of exchange before display of a disease. Shall be a basis of prevention of P. at children to lay down. the actions including not only use of antibacterial drugs, but also elimination of the factors contributing to emergence of microbic and inflammatory process in kidneys and uric ways.



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A. Ya. Pytel, K. A. Velikanov; 3. P. Grashchenkova (academician), V. P. Lebedev (ped.), N. K. Permyakov (stalemate. An.).

Яндекс.Метрика