CHRONIC PYELONEPHRITIS

Chronic pyelonephritis - a progressive inflammation of the tissue and renal tubules,

causing destructive changes in the cup-lohanoch-term shrinkage of the system and
kidneys. The disease is characterized by long latent or recurrent course.

Chronic pyelonephritis usually develop as the outcome of an acute process. The

transition of acute pyelonephritis in a chronic contributing factors leading to urostazu
(dysplasia of renal parenchyma, uric mochetoch-workers reflux), cystitis,
vulvovaginitis, altered reactivity of the organism of the child and inadequate treatment
of acute pyelonephritis. In some cases, chronic pyelonephritis develops gradually and
is not accurately set the beginning (primary chronic pyelonephritis).

Clinical picture

Clinical manifestations of the disease less pronounced than in acute pyelonephritis,

and depend on both the etiology and pathogenetic nature of the pathological process
(primary, secondary) and on the characteristics of the flow (manifest with recurrent or
latent).

When you manifest with recurrent pyelonephritis during recurrent episodes of

exacerbation alternating with more or less prolonged asymptomatic periods. Relapses
are often triggered by intercurrent diseases (usually ARI). During a relapse of
symptoms of the disease include fever, chills, abdominal pain (more often than in the
lumbar spine), dysuria, and inflammatory changes in peripheral blood, characteristic
changes in the urine, bacterial riuriyu. Outside the acute symptoms rather
scanty. Some children noted fatigue, headache, pale skin and visible mucous
membranes, asthenization, reflecting chronic intoxication. Changes in the urine during
this period are less distinct, the number of leukocytes in the sediment significantly
decreased bacteriuria is often missing.

When a latent course of chronic pyelonephritis clinical manifestations are absent, but
they show changes in the urine (leykotsituriyu, tank-teriuriyu). Diagnosis is made
with a random identification leykotsiturii and sometimes bacteriuria in children
undergoing examination with prophylactic or other purposes. However, in such cases,
careful observation of the child can detect signs of chronic intoxication. Beginning in
childhood, chronic pyelonephritis lasts sometimes more than one

ten years, appearing parts or rare episodes in certain periods of life (eg during
pregnancy). The rest of the time these people consider themselves
healthy. Nevertheless, persistence of infection in the renal tissue, slowly developing
structural changes and Nephrosclerosis eventually lead to renal failure and arterial
hyper-pertenzii. In the majority of cases the process becomes manifest in adulthood, at
far come and already irreversible changes in the kidneys. In children, arterial
hypertension as one of the signs of pyelonephritis only observed in 1.5% of cases (for
example, when fully developed CRF). In adults, increased blood pressure occurs in
10-25% of cases already in the initial stage of the disease.

On materials of the European Association of hemodialysis and kidney transplantation,

chronic pyelonephritis is ranked third as a cause of renal failure in children, yielding
the frequency of glomerulonephritis, hereditary and congenital nephropathy.

Diagnosis

Diagnosis of chronic pyelonephritis are often difficult, especially in cases of latent

flow. In view of the paucity of changes in the sediment of urine tests must be
repeated, using quantitative methods for counting the formed elements (samples
Kakovsky-Addis, Nechiporenko). If necessary, resort to provocative tests (eg, use
prednizolonovy test). Very informative X-ray and radiological examination of
patients.

With the help of excretory urography can specify the sizes, contours, location and
mobility of the kidneys, the state pyelocaliceal system, ureters, bladder, and calculate
renokor-tikalny index and determine the suitability of the area of kidney age of the
child.

Miktsionnaya urethrography allows to exclude or confirm the presence of reflux,

infravesical obstruction and get an idea of the shape and size of the bladder, urethra
status, the presence of diverticula and stones.

When cystoscopy determine the nature of changes in the mucosa of the bladder,
abnormalities of development, the location and shape of the mouths of the ureters.

Radioisotope renography reveals predominantly unilateral violation of secretion and

excretion of the isotope proximal tubules, reduced renal plasma flow.

Dynamic nefrostsintigrafiya provides information on the status of a functioning renal

parenchyma.

Outlook Study of urine for the presence of AT, fixed in bacteria, using the
RIF. Taking into account the possibility of development of chronic pyelonephritis as a
complication of metabolic disorders or hereditary tubulopatii, each patient should
determine the excretion of amino acids, phosphorus, oxalate and urate.
In the diagnosis of chronic pyelonephritis (as well as acute), reflecting a primary or
secondary illness, the nature of the flow (recurrent, latent) period (active, partial or
complete clinical and laboratory remission), the functional state of kidneys (saved or
broken features), the stage of disease (compensation , CRF). To this end, a kidney
function test, blood determine KSCHS, the concentration of sodium, potassium, urea,
creatinine.

Differential Diagnosis

The differential diagnosis conducted primarily with chronic cystitis. In connection

with minor modifications of the urinary sediment oligosymptomatic during
pyelonephritis is necessary to differentiate it from an inflammation of the external
genitalia (vulvitis, vulvovaginitis, balanoposthitis), which prescribe advice of child
gynecology and urology, as well as a study of vaginal and urethral smears.

Big difficulties are encountered in delineation of chronic pyelonephritis in the

terminal stage and chronic glomerulonephritis. In this case, the exclusion of interstitial
nephritis, evolving under the influence of nephrotoxic agents, tuberculosis renal
tumors, especially in unilateral pyelonephritis. Takes into account medical history,
tuberculin tests, clinical and radiologic examination of patients, the results of urine on
mycobacterium tuberculosis.

Treatment

If exacerbation of chronic pyelonephritis shows hospitalization, the child should stay

in bed all the hectic period. Later, once the normal body temperature, away dysuria
and back pain, it is not necessary (even with the continuing changes in urine),

Assign a diet closer to the table number 5 on Pevzner, consisting mainly of dairy and
vegetable dishes and takes into account the level of excretions-benefiting salts. After
the acute period, the 7-day 10, injected meats and fish. Excludes spices, extractives,
canned, roasted meat. In connection with polyuria, fever and intoxication recommend
drinking plenty of stewed fruit, fruit drinks, jelly, juices, mineral water.

Drug therapy is aimed at eliminating the bacterial inflammation. Her conduct

sustained, systematic way. In a feverish period treated with antibiotics, preferring the
less oil-rotoksichnye of them (duration of treatment 1 - 10 days, sometimes up to 15
days, may repeat courses). At the age of CRF dose reduced by half or one
third. Remediation of urine does not mean the suppression of infection in the renal
tissue, so after 1-2 courses antibiotikotera-FDI treatment continued until 6 months,
alternating with other nitrofurans urosep-tics (see above section "Acute
pyelonephritis"). Once a leukocyte-Uriah will be removed or stabilized at a minimal
level, intermittent therapy is carried out by the gradual lengthening of the intervals
between medication up to 10-20 days in each month. The presence of vesicoureteral
reflux, often the underlying chronic pyelonephritis requires lengthening the period of
active treatment and 10-12 months. Thereafter, the failure of conservative therapy
raise the question of rapid elimination of reflux. Distinct symptoms associated cystitis
appoint a special treatment (intravesical instillation of drugs, forced urination every
2,5-3 hours, physiotherapy procedures to the area of the bladder). In between taking
drugs recommend drinking cranberry and cranberry juice, herbal medicine.

Prolonged, recurrent, torpid to treatment of chronic pyelonephritis, which is suspected

of immunological failure macroorganism in the medical complex should include
means of influencing the immune status. These include lysozyme, preparations of
interferon alpha (viferon, reaferon, etc.).

Because pyelonephritis is damage to cell membranes, justified the appointment of

antioxidants. Applied vitamins A, E, B 6, es-sentsiale and other drugs that promote the
normalization of lipid peroxidation indices. In chronic pyelonephritis shows the use of
anti-sclerotic (drugs aminohinolinovo-goryada).

In the period of persistent clinical and laboratory remission for children prescribe
quenched procedure (sponging, swimming in indoor pools), massage, medical
gymnastics.

Prevention

Prevention of infectious inflammation of the urinary system provides for the first
observance of hygienic measures of child care, especially for girls. It is unacceptable
for a long stay in their diapers and nappies, contaminated faeces. It is important and
the prevention of DCI, helminthic infestations, as well as the elimination of chronic
inflammatory foci and strengthen body defenses. It should be remembered that each
child after any infectious disease must assign a urine sample. In order to prevent the
development of chronic pyelonephritis should adequately treat acute urinary infection.

All children with chronic pyelonephritis, subject to permanent dispensary observation.

Dispensary Goals - relapse prevention, control of urine and renal function status, the
definition of a dietary regime and amount of physical exertion, as well as the timing of
immunization. Mandatory testing otolaryngologist and dentist 1 time in 6 months. In
the event of intercurrent disease appoint antirecurrent treatment.

Forecast
Recovery occurs in 25-33% of children with primary chronic pyelonephritis, the rest
of the pathologic process persists. Arterial hypertension occurs in children with an
increase in nephrosclerosis changes, ie with the development of chronic renal failure
(this happens rarely, usually with pyelonephritis with obstructive uropathies or
dysmetabolic disorders). Exacerbations of the disease caused by intercurrent
infections, contribute to the progression of pyelonephritis, more rapid development of
renal failure and hypertension.