Alcoholic nephropathy – chronic damage of kidneys of inflammatory character which cornerstone the autoimmune mechanisms induced by impact on an organism of ethyl alcohol and its metabolites are. Expressiveness of symptoms depends on pathology type, the asymptomatic current until development of symptoms of the chronic renal failure (CRF) prevails, at some forms the progressing gematuriya and hypertensia is observed. Diagnostics of an alcoholic nephropathy is made on the basis of the given fizikalny survey, laboratory and functional researches of work of kidneys. Treatment includes the ban on reception of alcoholic beverages and symptomatic therapy.
The alcoholic nephropathy is known also as a hepatic glomerulopatiya, alcoholic chronic glomerulonefrit (AHGN) or alcoholic IgA-nephrite. Synonymous names reflect the main stages of pathogenesis of a disease including involvement of other bodies (liver) and the autoimmune mechanism of damage of kidneys with participation of immunoglobulins of a class A. Distribution of AHGN is in direct interrelation with level of consumption of alcohol-containing production in various regions of the planet. Exact statistical data are unknown because of rather small quantity seeing a doctor (the reason of it is a long asymptomatic current). The fact that the alcoholic nephropathy quite often is a part of simptomokompleks under the name "alcoholic disease" complicates the accounting of such patients.
Reasons of an alcoholic nephropathy
There are several main theories of development of AHGN, there are no reliable and unambiguous data in favor of any of them yet. The reasons of lack of consensus consist in various clinical and morphological manifestations of an alcoholic nephropathy that gives the grounds to assume existence of several mechanisms of damage of an urinary system. Range of opinions concerning the nature of a disease quite wide – from statements that the nephropathy is a part of an alcoholic disease to offers to divide AN into slightly pathologies, similar on a current, with various etiology. The following is considered as the most recognized theories of development of this state:
- Immunological reasons. There is a number of immunological mechanisms of damage of tissues of kidneys which can be connected with alcoholic intoxication. First of all it is a sensitization to anti-genes of an alcoholic hyalin with release of the immunoglobulins A capable to damage membranes of nefron. The similar mechanism – direct cytotoxic influence of ethanol and products of his metabolism by means of stimulation of allocation of tsitokin.
- Infectious reasons. Some researchers believe that alcohol reduces the level of protection of an organism against infections, including a virus of hepatitis C and some bacteria (colibacillus). It along with direct impact of infectious agents on various target organs is resulted by indirect damage of kidneys.
- System reasons. Ethanol is system poison, at the long use provokes increase in arterial pressure, damage of a liver, GIT, pancreas, metabolic violations (anomaly of purinovy exchange). There is an opinion that these factors play the defining role in pathogenesis of an alcoholic nephropathy.
Modern researchers incline to opinion that development of AHGN has the multiple-factor nature, all above-mentioned processes participate in pathogenesis of bigger or smaller degree. The role of genetic predisposition is unknown though existence of a wide range of specific features of a disease indicates its existence. Earlier postponed pathologies of kidneys, diabetes, arterial hypertension can act as risk factors, however in similar cases to differentiate alcoholic glomerulonefrit from forms of a secondary nephropathy of other type extremely difficult.
The mechanism of development of an alcoholic nephropathy is very difficult because of large number of pathogenetic factors, influence of each of which strongly differs at different patients. It suggests to some researchers that AHGN – only a component of simptomokompleks of an alcoholic disease. Practically IgA antibodies against components of a nefron are found in all patients that speaks about the autoimmune mechanism of pathogenesis. At reception of high doses of ethanol the last can directly stimulate allocation of tsitokin in kidneys that leads to destruction of nefron.
At the systematic use of alcohol metabolites of ethanol cause injury of a liver, nervous system, a pancreas, vessels of the microcirculator course. It indirectly strengthens defeat of bodies of an urinary system. Increase HELL, typical for chronic alcoholism, in itself is capable to lead to a secondary nephropathy. Metabolic failures, in particular exchange of purin, raise load of eliminative organs and also lead to violation of their functions up to chronic insufficiency. Expressiveness and speed of development of manifestations of AHGN depends on volumes of the consumed alcohol – a critical dosage the figure over 35 ml a day is considered.
Allocate several forms of an alcoholic nephropathy, the difference between them consists in the clinical course, existence or absence of associated diseases. It is quite easy to confuse some types of a state with other types of a secondary nephropathy because of similar manifestations and mechanisms of pathogenesis. Distinctive feature of AHGN is that circumstance that the prime cause of all pathological changes in an organism directly or indirectly worsening work of kidneys is abuse of alcohol. Existence of the following types of a disease is conventional:
- Latent form. Is the most widespread and it is difficult for the giving-in diagnostics because of almost total absence of subjective symptoms. Arises not only at the people who are constantly taking alcoholic drinks but also at those who do it with a certain frequency (1-2 times a week). The aggravations soon after the last alcohol intake which are shown reduction of functional activity of kidneys that is confirmed by laboratory researches are characteristic. In pathogenesis the role of direct nefrotoksichesky influence of ethanol prevails.
- Gipertenzivny form. More rare type of pathology which is generally arising at the persons having alcoholism, obesity and arterial hypertension. The last circumstance causes difficulties of distinction of AHGN of this type and a secondary gipertenzivny nephropathy. Damage of nefron happens at development of haemo dynamic and metabolic violations, kanaltsevy acidosis.
- Nephrotic form. Extremely rare and most severe form of a chronic alcoholic nephropathy. Is followed by the progressing diffusion glomerulonefrit quickly enough leading to HPN. The main link of pathogenesis – a sharp sensitization of an organism and autoimmune defeat of fabrics immunoglobulins A.
Some authors rank as an alcoholic nephropathy sharp states, for example, a sharp renal failure at poisoning with alcoholic drinks. In spite of the fact that at the same time direct nefrotoksichesky activity of ethanol is most brightly shown, OPN at alcoholic intoxication differs on the mechanism of development from other injuries of kidneys against the background of AHGN. Therefore most of experts do not consider such state as a classical nephropathy.
Symptoms of an alcoholic nephropathy
In most cases the disease proceeds almost asymptomatically, displays of pathology are registered incidentally when performing laboratory researches on other occasion. It is especially characteristic of a latent form – quite often asymptomatic current can last for many years. The aggravations arising for 1-3 days after the ethanol use can be shown only by complaints to decrease in volume of urine (oliguriy) and is extremely rare – mild nagging pains in a waist. At a long current into the forefront displays of an alcoholic disease act: an eritema of palms, a ginekomastiya at men, symptoms of damage of a pancreas and liver (pain in a podreberye and a stomach, jaundice).
The Gipertenzivny option of an alcoholic nephropathy at the initial stages of development is also characterized by weak expressiveness of actually nefrogenny symptoms. The patient complains of headaches, rushes of blood to the person, unpleasant feelings in heart and other investigations of elevated pressure of blood. Quite often this type of a disease is followed by obesity. For the AHGN nephrotic form the rapid current is typically enough – usually after an excess there is an oliguriya, a visible gematuriya, deterioration in the general state. Surely there are ekstrarenalny displays of chronic intoxication ethanol.
In the absence of medical measures and the continuing intake of ethyl alcohol in an organism the alcoholic nephropathy steadily comes down to emergence of HPN. Its signs are the fatigue, the broken state, the headache amplifying after reception of ethyl alcohol. Then there is an ammoniac smell from a mouth, strong thirst, vomiting, dryness of skin, an inflammation of mucous membranes. The amount of the emitted urine sharply decreases, on a surface of integuments the whitish raid is formed of the urea emitted by sweat glands.
Not always it is possible to differentiate strictly complications of actually alcoholic nephropathy and intoxication ethyl alcohol. At AHGN there is alcoholic poisoning which is followed by a sharp renal failure with an anury, a headache, vomiting, hypostases and other symptoms of uraemia much easier. Considering the progressing character of a state, can lead earlier habitual dosages of alcohol to sharp poisoning that increases risk of development of a complication. The uraemic coma caused by intoxication the metabolism products which are not removed through kidneys can act as a terrible and adverse complication.
For diagnostics of an alcoholic nephropathy use methods of fizikalny survey, a number of laboratory analyses and tool researches. Consultation of the doctor-nephrologist is necessary, can sometimes connect the narcologist to definition of a state. Usually the algorithm of diagnostics of AHGN includes the following stages:
- Inquiry and collecting anamnesis. Degree of dependence of the patient on alcohol (which directly correlates with expressiveness of damage of kidneys), duration of abuse and its character (continuous or periodic "zapoyny" consumption) is defined. It is important to specify prescription of the last excess and approximate amount of the used ethyl alcohol.
- Fizikalny survey. Especially pay attention to ekstrarenalny symptoms of alcoholism: erity palms, darkening of skin, increase in the sizes of a liver, a ginekomastiya at men. In some cases reveal increase in pressure, obesity. Detection of an ammoniac smell from a mouth, the unpleasant "uric" smell of sweat, dryness of skin, a white raid on it speak about development of HPN and uraemia.
- Laboratory methods of a research. Quite often general analysis of urine made in other occasion reveals existence of an alcoholic nephropathy. Its results at AHGN are the mikrogematuriya and a moderate proteinuria which indicators increase after alcohol drinking. Besides OAM for diagnostics of a state use the biochemical blood test, functional kidney tests (Reberg's test, Zimnitsky) indicating decrease in level of a glomerular filtration (reduction of clearance of creatinine to 30 ml/min. and less, an oliguriya).
- Ultrasonic diagnostics. For definition of a state appoint ultrasonography of kidneys and doppler sonography (UZDG) of kidney vessels. At simple ultrasonography reduction of the sizes of kidneys, decrease in thickness of a parenchyma comes to light. Doppler sonography confirms the decrease in a kidney blood-groove correlating with expressiveness of a nephropathy. In addition can carry out ultrasonography of other bodies (a pancreas, mochetochnik, a liver) for assessment of their state.
In exceptional and disputable cases make a biopsy of a liver and kidneys for histologic studying of data of bodies. At an alcoholic nephropathy in a liver symptoms of hyaline and drop dystrophy, in kidneys – mezangioproliferativny nephrite of diffusion or focal character will be defined. X-ray contrast methods of a research (for example, urography) appoint with care because of a nefrotoksichnost of the majority of contrast agents. The differential diagnosis is carried out with other types of primary and secondary nefropatiya, the defining factor it becomes frequent the fact of existence of long abuse of alcohol.
Treatment of an alcoholic nephropathy
The main and fundamental appointment is the total ban of the use of alcoholic beverages. Only at refusal of alcohol more than at a half of patients with a latent form of an alcoholic nephropathy permanent improvement of laboratory indicators of urine and almost full remission is observed. Non-compliance with this instruction even at implementation of other recommendations and therapeutic measures slows down progressing of a state some. At the started cases of AHGN and existence of the accompanying pathologies besides refusal of alcoholic drinks appoint a number of auxiliary therapeutic measures:
- Antigipertenzivny therapy. The lowering of arterial pressure well influences the forecast for the reason of elimination of haemo dynamic violations in kidneys. This component of treatment at gipertenzivny forms of a nephropathy is especially important. At violations of work of secretory system for pressure decrease use APF inhibitors, blockers of calcic channels and receptors to angiotensin 2.
- Metabolism normalization. Metabolic disorders become a consequence of alcoholic intoxication often: purin, carbohydrates, fats. By means of special diets it is necessary to normalize metabolism and to lower load of secretory system. Especially harmful kidneys are affected by violation of allocation of purin therefore at insufficient efficiency of dietary food anti-gouty medicines can be appointed ().
- Resolvents. At bystry progressing of a state (a nephrotic form) use kortikosteroidny and cytostatic medicines. The purpose of their application – to reduce activity of inflammatory processes for reduction of a damage rate of kidneys. Today their efficiency is criticized by a number of researchers.
When diagnosing HPN carrying out a hemodialysis which frequency depends on extent of defeat of secretory system is recommended. In treatment of an alcoholic nephropathy the narcologist can play a supporting role – with his help to the patient will easier get rid of dependence. Use of pharmacological means in fight against alcoholism should be made taking into account the lowered speed of a glomerular filtration.
Forecast and prevention
In case of strict observance of the ban on alcohol intake and early identification of a pathological state the forecast of an alcoholic nephropathy practically always favorable – functions of secretory system are restored almost in full. In the presence of the accompanying violations caused by abuse of alcohol-containing production, the outcome of pathology depends on their high-quality treatment. At HPN recovery of normal work of kidneys is almost always impossible, but the supporting treatment is capable to keep the acceptable quality of life of the patient for many years. The combination of AHGN and heavy displays of an alcoholic disease possesses the most adverse forecast: cirrhosis, alcoholic pancreatitis, cardiomyopathy. But also in this case long-term complex treatment can improve a condition of the patient considerably.