Chronic pyelonephritis – the chronic nonspecific bacterial process proceeding mainly with involvement of interstitsialny tissue of kidneys and cup complexes. Chronic pyelonephritis is shown by an indisposition, dull aches in a waist, subfebrilitety, dizurichesky symptoms. In the course of diagnosing of chronic pyelonephritis conduct laboratory researches of urine and blood, ultrasonography of kidneys, a retrograde piyelografiya, a stsintigrafiya. Treatment consists in observance of a diet and the sparing mode, purpose of antimicrobic therapy, nitrofurans, vitamins, physical therapy.
In nephrology and urology chronic pyelonephritis makes 60-65% of cases of all inflammatory pathology of urinogenital bodies. In 20–30% of observations the chronic inflammation is an outcome of sharp pyelonephritis. Chronic pyelonephritis mainly develops at girls and women that is connected with the morfo-functional features of a female urethra facilitating penetration of microorganisms into a bladder and kidneys. More often chronic pyelonephritis has bilateral character, however at the same time extent of damage of kidneys can differ.
Alternation of the periods of an aggravation and subsiding (remission) of pathological process is characteristic of the course of chronic pyelonephritis. Therefore in kidneys polymorphic changes – the inflammation centers in various stages, cicatricial sites, zones of not changed parenchyma at the same time come to light. Involvement in an inflammation everything new sites of the functioning renal fabric causes her death and development of the chronic renal failure (CRF).
Reasons of chronic pyelonephritis
The Etiologichesky factor causing chronic pyelonephritis is microbic flora. Mainly it is kolibatsillyarny bacteria (paraintestinal and colibacillus), enterokokk, proteas, staphylococcus, a sinegnoyny stick, streptococci and their microbic associations. A special role in development of chronic pyelonephritis is played by the L-forms of bacteria which are formed as a result of inefficient antimicrobic therapy and changes Wednesdays. Similar microorganisms differ in resistance to therapy, difficulty of identification, ability is long to remain in interweft fabric and to become more active under the influence of certain conditions.
In most cases chronic pyelonephritis is preceded by the sharp attack. Synchronization of an inflammation is promoted by not eliminated urine outflow violations caused by stones in kidneys, striktury a mochetochnik, a puzyrno-mochetochnikovy reflux, nefroptozy, prostate adenoma etc. Can support an inflammation in kidneys other bacterial processes in an organism (uretrit, prostatitis, cystitis, cholecystitis, appendicitis, enterokolit, tonsillitis, otitis, sinusitis and so forth), all-somatic diseases (diabetes, obesity), conditions of a chronic immunodeficiency and intoxications. Pyelonephritis combination cases to a chronic glomerulonefrit meet.
At young women the beginning of sex life, pregnancy or childbirth can be a push to development of chronic pyelonephritis. At children of younger age chronic pyelonephritis is often connected with the congenital anomalies (to the ureterotsela, bladder diverticulums) breaking an urodinamika.
Classification of chronic pyelonephritis
Chronic pyelonephritis is characterized by course of three stages of an inflammation in renal fabric. At the I stage leykotsitarny infiltration of interstitsialny fabric of brain substance and an atrophy of collective tubules is found; kidney balls of an intaktna. At the II stage of inflammatory process cicatricial and sclerous defeat of an interstition and tubules is noted that is followed by death of terminal departments of nefron and a sdavleniye of tubules. At the same time the gialinization and a zapustevaniye of balls, narrowing or an obliteration of vessels develop. In a final, III stage of chronic pyelonephritis renal fabric is replaced cicatricial, the kidney has the reduced sizes, looks wrinkled with a hilly surface.
On activity of inflammatory processes in renal fabric in development of chronic pyelonephritis allocate phases of an active inflammation, a latent inflammation, remission (clinical recovery). Under the influence of treatment or in its absence the active phase of chronic pyelonephritis is replaced by a latent phase which, in turn, can turn into remission or again in an active inflammation. The phase of remission is characterized by lack of clinical symptoms of chronic pyelonephritis and changes in analyses of urine. On clinical development of chronic pyelonephritis allocate erased (latent), recidivous, hypertensive, anemichesky, azotemichesky forms.
Symptoms of chronic pyelonephritis
The latent form of chronic pyelonephritis is characterized by poor clinical manifestations. Patients are usually disturbed by a general malaise, bystry fatigue, subfebrilitt, a headache. The uric syndrome (a dizuriya, waist pains, hypostases), as a rule, is absent. Pasternatsky's symptom can be poorly positive. The small proteinuria, the alternating leykotsituriya, a bakteriuriya is noted. Violation of concentration function of kidneys at a latent form of chronic pyelonephritis is shown by a gipostenuriya and a polyuria. At some patients insignificant anemia and a moderate hypertension can come to light.
The recidivous option of a course of chronic pyelonephritis proceeds wavy with periodic activization and a zatikhaniye of an inflammation. As manifestations of this clinical form serve weight and the aching waist pain, dizurichesky frustration, periodic feverish states. In a phase of an aggravation the clinic of typical sharp pyelonephritis develops. When progressing recurrent chronic pyelonephritis the hypertensive or anemichesky syndrome can develop. Laboratory, especially at an exacerbation of chronic pyelonephritis, the expressed proteinuria, a constant leykotsituriya, a tsilindruriya and a bakteriuriya, sometimes – a gematuriya is defined.
At a hypertensive form of chronic pyelonephritis prevailing there is a gipertenzivny syndrome. Arterial hypertension is followed by dizziness, headaches, hypertensive crises, sleep disorders, short wind, a heartache. At chronic pyelonephritis the hypertension quite often has malignant character. The uric syndrome is, as a rule, not expressed or carries the alternating current.
The Anemichesky option of chronic pyelonephritis is characterized by development of gipokhromny anemia. The hypertensive syndrome is not expressed, uric – changeable and poor. Unite cases when the disease comes to light only at HPN stage in an azotemichesky form of chronic pyelonephritis. Clinical and laboratory data of an azotemichesky form are similar to that at uraemia.
Diagnosis of chronic pyelonephritis
Difficulty of diagnosis of chronic pyelonephritis is caused by variety of clinical options of a disease and its possible latent current. In the general analysis of urine at chronic pyelonephritis the leykotsituriya, a proteinuria, a tsilindruriya comes to light. The urine research on Addis-Kakovsky's technique is characterized by prevalence of leukocytes over other elements of an uric deposit. Bacteriological crops of urine promote identification of a bakteriuriya, identification of causative agents of chronic pyelonephritis and their sensitivity to antimicrobic medicines. Zimnitsky's tests, Reberg, biochemical blood test and urine are applied to assessment of a functional condition of kidneys. In blood at chronic pyelonephritis gipokhromny anemia, acceleration of SOE, neytrofilny is found.
Extent of violation of functions of kidneys is specified by means of carrying out a hromotsistoskopiya, excretory and retrograde urography, a nefrostsintigrafiya. Reduction of the sizes of kidneys and structural changes in renal fabric come to light according to ultrasonography of kidneys, KT, MPT. Tool methods at chronic pyelonephritis objectively indicate reduction of the sizes of kidneys, deformation cup structures, decrease in sekretorny function of kidneys.
In clinically not clear cases of chronic pyelonephritis the kidney biopsy is shown. Meanwhile, the fence during a biopsy of not struck renal fabric can yield false-negative result at a morphological research of a bioptat. In the course of differential diagnostics it is excluded kidneys, chronic glomerulonefrit, a hypertension, diabetic .
Treatment of chronic pyelonephritis
Observance of the sparing mode with an exception of the factors provoking an aggravation is shown to patients with chronic pyelonephritis (overcoolings, colds). Adequate therapy of all interkurrentny diseases, periodic control of analyses of urine, dynamic observation of the urologist (nephrologist) is necessary.
Recommendations about a diet include refusal of hot dishes, spices, coffee, alcoholic beverages, fish and meat gains. The diet has to be vitaminized, with the maintenance of dairy products, vegetable dishes, fruit, boiled fish and meat. In days it is necessary to use not less than 1,5-2 l of liquid not to allow excessive concentration of urine and to provide washing of uric ways. At exacerbations of chronic pyelonephritis and at its hypertensive form restrictions for reception of table salt are imposed. At chronic pyelonephritis cranberry drink, water-melons, pumpkin, melons are useful.
The exacerbation of chronic pyelonephritis demands purpose of antibacterial therapy taking into account microbic flora (penicillin, tsefalosporin, aminoglycosides, ftorkhinolon) in combination with nitrofurans (furasolidone, ) or medicines of nalidiksovy acid. The system chemotherapy proceeds before the termination of a bakteriuriya by laboratory results. In complex medicamentous therapy of chronic pyelonephritis vitamins B are used, And, With; antihistamines (, , ). At a hypertensive form hypotensive and spazmolitichesky medicines are appointed; at anemichesky – iron medicines, B12 vitamin, folic acid.
At chronic pyelonephritis the physical therapy is shown. Especially well SMT-therapy, galvanization, an electrophoresis, ultrasound, chloride sodium bathtubs and so forth proved. In case of development of uraemia carrying out a hemodialysis is required. Far come chronic pyelonephritis which is not giving in to conservative treatment and followed by unilateral wrinkling of a kidney, arterial hypertension is the basis for a nefrektomiya.
Forecast and prevention of chronic pyelonephritis
At latent chronic pyelonephritis patients a long time keep working capacity. At other forms of chronic pyelonephritis working capacity decreases sharply or lost. Terms of development of a chronic renal failure are variable and extents of violation of functions of kidneys depend on clinical option of chronic pyelonephritis, frequency of aggravations. Death of the patient can occur from uraemia, sharp violations of brain blood circulation (a hemorrhagic and ischemic stroke), heart failure.
Prevention of chronic pyelonephritis consists in timely and active therapy of sharp uric infections (an uretrit, cystitis, sharp pyelonephritis), sanitation of the centers of an infection (chronic tonsillitis, antritis, cholecystitis, etc.); elimination of local violations of an urodinamika (removal of stones, section , etc.); immunity corrections.