|
Arabic
Bengali
Chinese
English
French
German
Hebrew
Hindi
Italian
Japanese
Korean
Malay
Polish
Portuguese
Spanish
Turkish
Ukrainian
Vietnamese|
Lecture notes, cheat sheets
Hospital therapy. Kidney diseases. Pyelonephritis (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 16. Diseases of the kidneys. Pyelonephritis Pyelonephritis is an infectious disease in which the renal pelvis, its calyces and the substance of the kidneys are involved in the process, with a predominant lesion of the interstitial tissue. In this regard, pyelonephritis is interstitial (interstitial) nephritis. This is a broader concept than pyelonephritis. It denotes, firstly, a type of inflammation of the kidneys of any etiology with predominant involvement of the interstitium, and secondly, a special disease in which this inflammation is its only and main expression. Close to interstitial nephritis is the so-called tubulo-interstitial nephritis, in which there is a friendly lesion of the tubules and stroma of the kidneys. Classification. Based on clinical and morphological data, acute and chronic pyelonephritis is distinguished, which usually has a recurrent course in the form of attacks of acute pyelonephritis. Also, pyelonephritis can be one- and two-sided. According to the form of the course (for chronic pyelonephritis): recurrent form, latent chronic pyelonephritis, pyelonephritic wrinkled kidney. Etiology and pathogenesis. Pyelonephritis is an infectious disease. Its causative agents are infectious agents of a nonspecific nature: E. coli, enterococcus, staphylococcus and other bacteria, but in most cases we are talking about E. coli (40%) and mixed flora (38%). Attention is drawn to the L-forms of bacteria, protoplasts (the bodies of bacteria, devoid of membranes that can support infection), candida, which can cause chronic pyelonephritis. Sources of infection can be tonsillas, diseases of the genital organs and large intestine, i.e. infectious agents can penetrate the kidney, including the pelvis, with the blood stream (hematogenous descending pyelonephritis), which is observed in many infectious diseases (typhoid fever, influenza , angina, sepsis). More often, microbes are brought into the kidneys in an ascending way from the ureters, bladder, urethra (urogenic ascending pyelonephritis), which is facilitated by dyskinesia of the ureters and pelvis, increased intrapelvic pressure (vesicorenal and pyelorenal reflux), as well as reabsorption of the contents of the pelvis into the veins of the renal medulla ( pyelovenous reflux). Ascending pyelonephritis, as a rule, complicates those diseases of the genitourinary system, in which the outflow of urine is difficult (stones and strictures of the ureters, strictures of the urethra, tumors of the genitourinary system), so it often develops during pregnancy. Lymphogenic infection in the kidneys (lymphogenic pyelonephritis) is also possible, when the colon and genital organs are the source of infection. For the development of pyelonephritis, in addition to the penetration of infection into the kidneys, the reactivity of the body and a number of local causes that cause a violation of the outflow of urine and urinary stasis are of great importance. The same reasons explain the possibility of a recurrent chronic course of the disease. Infected microorganisms with functional and morphological changes in the urinary tract leading to urinary stasis, impaired venous and lymphatic outflow from the kidney, contributing to the fixation of infection in the kidneys, cause focal and polymorphic zones of inflammatory infiltrates and suppuration of the interstitium of one or both kidneys. The interstitial tissue of the tubules is affected, and then the nephrons. There are productive endarteritis, hyperplasia of the middle shell of the vessels, the phenomena of hyalinosis, arteriolosclerosis develop up to the secondary wrinkled kidney. In recent years, a certain role in the development of chronic pyelonephritis is assigned to autoimmune reactions: under the influence of bacterial antigens, immunoglobulin G and complement are deposited on the basement membrane of the glomerular capillaries, causing its damage. The transition of acute pyelonephritis to chronic is facilitated by: belated diagnosis of acute pyelonephritis, untimely hospitalization, the presence of chronic infections, diabetes mellitus, gout, and the abuse of analgesics - phenacetin. Chronic pyelonephritis is more common in women (50%), which is facilitated by pregnancies, especially repeated ones (estrogens cause atony of the smooth muscles of the urinary tract), in childhood in girls, which is associated with the structure of the urinary tract, their anomalies. clinical picture. As mentioned above, both acute and chronic course of pyelonephritis is possible. The clinical picture of the acute phase of the disease is characterized by a sudden, sharp increase in body temperature up to 39-40 ° C, the onset of weakness, headache, chills, combined with profuse sweating, nausea and vomiting may occur. Along with the rise in body temperature, pains appear in the lumbar region, which, as a rule, are noted on one side. The nature of the pain is dull, their intensity is different. In the case of the development of the disease against the background of urolithiasis, an attack of pyelonephritis is preceded by an attack of renal colic. In the absence of adequate therapy, the disease can become chronic, or this leads to the development of suppurative processes in the kidney, which are clinically manifested by a deterioration in the general condition of the patient and sudden changes in temperature (from 35-36 ° C in the morning to 40-41 ° C in the evening). Chronic pyelonephritis is, as a rule, a consequence of undertreated acute pyelonephritis, when it was possible to remove acute inflammation, but it was not possible to radically destroy all pathogens in the kidney, nor to restore the physiological outflow of urine from the kidney. Chronic pyelonephritis is disturbed by constant dull aching pains in the lumbar region, aggravated in damp cold weather. Also, chronic pyelonephritis is prone to periodic exacerbations, when the patient has all the signs of an acute process. Diagnostics. The problem of diagnosing the disease is due to the fact that the symptoms of pyelonephritis are similar to the symptoms of other diseases resulting from inflammation of the urinary tract. The diagnostic examination plan includes blood tests, urine tests, as well as studies showing the state of the urinary system: ultrasound of the kidneys, X-ray studies, PCR analysis for an infectious agent. To verify the type of infectious agent, it is necessary to conduct a bacteriological culture of a urine sample, and the method of computed tomography is used to exclude tumor processes. Thus, laboratory and special research methods are of great importance for the recognition of the disease. And in chronic pyelonephritis, the decisive, and sometimes the only manifestations are changes in the urine, blood and urinary tract. It is necessary to dynamically monitor blood pressure and weight of the patient. Leukocytosis, increased ESR, neutrophilic shift are noted in the blood, an increase in the level of residual nitrogen (at a norm of 20-40 mg), urea (norm 40-60 mg), creatinine (norm 53-106 μmol / l), indican (norm 1,41, 3,76-180 µmol/l), cholesterol (norm 200-83 mg), blood chlorides (norm XNUMX mmol/l). Important for the diagnosis of changes in the urine: a decrease in specific gravity, proteinuria (including daily), hematuria and cylindruria. However, methods for quantitative determination of the formed elements of urine sediment are gaining increasing diagnostic importance: Kakovsky-Addis (normal leukocytes up to 4 million; red blood cells - up to 1 million, cylinders - up to 2 thousand in 24 hours), Amburger (normal leukocytes up to 2000 , red blood cells - up to 1400, casts - up to 20 per 1 min), Nechiporenko (normal leukocytes up to 2500, red blood cells - up to 1000, casts - up to 20 in 1 ml of freshly released urine). The ratio of the absolute number of erythrocytes and leukocytes in the urine sediment with pyelonephritis changes dramatically towards a significant predominance of leukocytes by 10-20 times. In chronic pyelonephritis, Stenheimer-Malbin cells appear in the urine: large leukocytes, with Brownian movement of cytoplasmic granules, appearing with a decrease in the osmotic properties of urine (specific gravity below 10-14), stained blue with gentian violet and safronin, "active" leukocytes: altered leukocytes , possessing the Brownian motion of the protoplasm, revealed when stained with a 1% aqueous solution of methylene blue with the addition of distilled water. The diagnostic value of an increase in the number of "active" leukocytes and Stenheimer-Malbin cells (up to 40%), bacteriuria (microbial count more than 100 thousand per 1 ml of urine), nitrite test (with a microbial count of more than 100 thousand U, microbes decompose urine nitrites) are emphasized. , with the addition of sulfanilic acid and L-naphthylamine, a red color appears), a colorimetric TTX test (under the action of microbial dehydrogenases, triphenyltetrazolyte chloride is reduced to red insoluble triphenylformazan within 4-10 hours at a temperature of -37 ° C), a provocative prednisolone test (the patient collects in a sterile dish, the middle portion of urine is the control one, then 30 mg of prednisolone in 10 ml of saline is slowly injected into the vein and the middle portion of urine is collected three times at hourly intervals and after 24 hours; in chronic pyelonephritis, the number of leukocytes, bacteria doubles, "active" leukocytes appear , at least in one portion), antibiograms. Particular attention should be paid to the microscopy of tuberculosis of the kidneys (microscopy of smears stained according to Tsil, sowing urine on special media - the method of Preis and Shkolnikova, the biological method). If a unilateral process is suspected, it is necessary to conduct a urine test, separately taken from each kidney with special catheters. An important role in the diagnosis of chronic pyelonephritis is played by radiological research methods: survey radiography and tomography (characterize the position, size and shape of the kidneys), excretory and retrograde pyelography (decrease in the concentration and excretory ability of the kidneys, spasms, anomalies, deformities of the pelvis, calyces), pneumopyelography (for recognition of non-contrast stones), renal angiography (reveals a violation of vascular architectonics - arteries and veins). To determine the safety of the function, and the parenchyma of the kidneys, especially with a unilateral process, radioindication methods are used - renography (hippuran iodine 131) and scanography (using neohydride Hg 203). Puncture biopsy in the case of pyelonephritis due to the foci of the process may not provide information. Chromocystoscopy may indicate kidney damage. Treatment. Most often, therapy for pyelonephritis is conservative, however, if acute pyelonephritis is purulent, surgical intervention may be required. Conservative treatment consists of a regimen, diet, the use of antibiotics, as well as various drugs that stabilize the function of the kidneys and the patient’s body as a whole. In acute pyelonephritis, strict bed rest is indicated. The food should be consumed foods containing the optimal amount of proteins, fats and carbohydrates. In the acute period, it is necessary to alternate protein and plant foods. With severe intoxication, you need to drink plenty of water. Treatment of chronic pyelonephritis consists of the impact on the infection (etiotropic) in primary pyelonephritis and the elimination of one or another cause in secondary pyelonephritis, pathogenetic mechanisms and treatment of complications. The most effective treatment is after determining the antibiogram. Continuous (at least 2 months) treatment with antibacterial drugs is carried out. Immediately upon admission, an antibiotic, sulfanilamide or nitrofuran drug is prescribed. After 1-10 days, the drugs are changed, the treatment is carried out until the persistent disappearance of leukocyturia and bacteriuria. As soon as the exacerbation is eliminated, intermittent treatment with one of the antibacterial agents is carried out for 4-5 months: the drug is given for 7 days, then a break is taken for 8-10 days, or the drug is given for 10 days with an interval of 15-20 days, or the drug is given for 15 days, the interval is made for 15 days, then antimicrobial therapy is prescribed again. The duration of treatment and intervals is determined by clinical symptoms and laboratory control. It should be pointed out that in case of pyelonephritis that has developed in a patient with chronic tonsillitis, antibiotics of the penicillin series are most effective; in case of genital infections in men and women, broad-spectrum antibiotics are used (see Table 12). In the presence of gram-negative flora, treatment with nalidixic acid gives good results (blacks, ievigramon - 1,0 g 4 times a day for 7 days, but its preparations should be prescribed less frequently than other drugs (2 times)). Of the sulfa drugs, etazol (1,0 g 4 times - 10 days), solafur (0,1 g 3 times), long-acting sulfonamides are used. Also, courses are treated with furazolidone, furadonin, furagin (0,1 g 4 times a day). It must be emphasized that renal function should be determined before starting treatment. Long-term antibiotic therapy should be carried out with a glomerular filtration rate of at least 30 ml / min or with a residual nitrogen content in the blood serum of not more than 70 mg. An indicator of the effectiveness of the drug after a week of treatment is a decrease in the microbial count to 10 in 000 ml of urine. It is possible to reduce the virulence of microflora and increase the effectiveness of antibacterial agents by changing the reaction of urine every 10-14 days. Alkalinizing food, sodium citrate (10 g per day), alkaline mineral waters help to reduce pH reactions. Some antibacterial action has sodium benzoate (4-6 g per day), which is abundant in cranberries and bearberries. Pathogenetic therapy should be aimed at increasing the body's reactivity, improving urine outflow, and normalizing blood pressure. To activate immunobiological reactivity, α-globulin, autohemotherapy, blood transfusion, vaccine therapy are used (autovaccine treatment is carried out for 30-40 days, 0,1 ml subcutaneously or 0,2-0,3 ml every 2 days), staphylococcal toxoid ( 0,1-0,3-0,5-0,7-1,0-1,2-1,7-2,0 ml every 3 days). Diuretic herbs (bearberry, juniper berries, field horsetail, orthosiphon leaf - kidney tea, lingonberry leaf), antispasmodics (papaverine, no-shpa, etc.) help to normalize the outflow of urine. If there is an obstruction to the flow of urine, surgical treatment is indicated. With concomitant hypertension, rauwolfia preparations are indicated - isobarine, dopegyt, hemiton, saluretics, aldosterone antagonists. Prevention and prognosis. Prevention of pyelonephritis consists of primary and secondary measures. Primary prevention includes, first of all, the treatment of diseases that can lead to the development of pyelonephritis: focal infections, urological diseases (such as urolithiasis, prostate adenoma, as well as any diseases accompanied by a violation of the outflow of urine from the kidney), recreational activities. Table 12 Comparative efficacy of antibacterial drugs in pyelonephritis
Secondary prevention includes the detection of bacteriuria during preventive examinations (for example, pregnant women should conduct a bacteriological analysis of urine at least once a month), the appointment of anti-relapse treatment: the first week of each month - a pause in treatment: rosehip decoction, the second, third week - herbal diuretics and antiseptics, the fourth week - antibacterial agents (nitrofurans, antibiotics, antiseptics, once a year - nevigramon 1 g 1 times during the week and 1,0 g - during the second week, or 4-NOC 2-5 mg 100 times a day 150-4 days). Anti-relapse treatment is carried out for 2-3 years. Dispensary examinations with treatment should be carried out 3-4 times a year or 4-6 times. Forecast. The prognosis depends on the stage of the disease. Spa treatment. Sanatorium-resort treatment is indicated during the period of remission, especially for patients with secondary calculous pyelonephritis after urological operations (Truskavets, Sairme, Zheleznovodsk, Berezovsky mineral waters), where patients take low-mineralized waters. Sanatorium-resort treatment is contraindicated in case of high hypertension, severe anemia and obvious renal failure. Complications of pyelonephritis are varied. In acute pyelonephritis, the progression of the purulent process leads to the fusion of large abscesses and the formation of a carbuncle of the kidney, the communication of purulent cavities with the pelvis (pyonephrosis), the transition of the process to a fibrous capsule (perinephritis) and perinephric tissue (paranephritis). Acute pyelonephritis can be complicated by necrosis of the papillae of the pyramids (papillonekrosis), which develops as a result of the direct toxic effect of bacteria in conditions of urinary stasis. This complication of pyelonephritis occurs in most cases in patients with diabetes. Rarely, pyelonephritis becomes a source of sepsis. With the restriction of the purulent process during the scarring period, abscesses surrounded by a pyogenic membrane (chronic kidney abscess) can form. In chronic pyelonephritis, especially unilateral, it is possible to develop nephrogenic hypertension and arteriolosclerosis in the second (intact) kidney. Bilateral pyelonephritic wrinkling of the kidneys leads to chronic renal failure. The outcome of acute pyelonephritis is usually recovery, but as a result of complications (pyonephrosis, sepsis, papilonecrosis), death may occur. Chronic pyelonephritis with wrinkling of the kidneys often ends with azotemia uremia. With the development of arterial hypertension of renal origin, lethal outcome in chronic pyelonephritis is sometimes associated with the complications that occur in hypertension (cerebral hemorrhage, myocardial infarction, etc.). Author: Mostovaya O.S. << Back: Kidney disease. Acute glomerulonephritis
▪ The main dates and events of domestic and foreign history. Crib ▪ Civil procedural law. Lecture notes
The existence of an entropy rule for quantum entanglement has been proven
09.05.2024 Mini air conditioner Sony Reon Pocket 5
09.05.2024 Energy from space for Starship
08.05.2024
▪ Fujitsu TeamPoS 7000 S Series Modular Controller for Retail ▪ New Science - Forensic Seismology ▪ Compact camera Olympus Stylus SH-1
▪ site section Clocks, timers, relays, load switches. Article selection ▪ article The impact of smoking on human health. Basics of safe life ▪ article Why is the drum round? Detailed answer ▪ Article Eight at one end. Tourist tips ▪ article Extender for pager. Encyclopedia of radio electronics and electrical engineering ▪ article Obedient coin. Focus secret
Home page | Library | Articles | Website map | Site Reviews
www.diagram.com.ua |
We recommend interesting articles Section 
See other articles Section 
Latest news of science and technology, new electronics:
All languages of this page