Clinical guidelines for the treatment of pyelonephritis in children. Pyelonephritis treatment clinical guidelines

Pyelonephritis, clinical recommendations for the treatment of which depend on the form of the disease, is inflammatory disease kidneys. Factors affecting the occurrence of pyelonephritis: urolithiasis disease, irregular structure of the urinary canals, renal colic, prostate adenoma, etc.

Anyone can get kidney inflammation. However, girls aged 18 to 30 are at risk; older men; children under 7 years old. Doctors distinguish two forms of pyelonephritis: chronic and acute.

Symptoms, diagnosis and treatment of acute pyelonephritis

Acute pyelonephritis is an infectious disease of the kidneys. The disease develops quickly, literally within a few hours.

Symptoms of acute inflammation of the kidneys:

• a sharp increase in temperature to 39 ° C and above;
• sharp pain in the lower back at rest and on palpation;
• back pain during urination;
• increased blood pressure;
• nausea or vomiting;
• chills.

In case of symptoms, you should immediately contact a urologist or nephrologist and do not self-medicate! The doctor must conduct a diagnosis to confirm the diagnosis. The fact of acute inflammation of the kidneys will help to identify general urine and blood tests (the level of leukocytes will significantly exceed the norm) and ultrasound of the kidneys. The doctor may additionally prescribe an MRI or CT scan.

Acute pyelonephritis should be treated permanently. At the same time, it is necessary to eliminate not only the symptoms, but also the causes of the disease themselves. If treatment is not started on time, acute pyelonephritis can develop into chronic, and then completely into renal failure.

Therapeutic treatment acute inflammation includes antibacterial drugs (antibiotics) and vitamins. In severe cases of inflammation, surgery may be necessary. In the first days of the disease, it is imperative to observe bed rest. At the same time, it is not even allowed to get up to use the toilet, which is why it is so important to undergo treatment in a hospital.

• Stay warm. You can't overcool.
• Drink plenty of fluids. An adult needs to drink more than 2 liters of fluid per day. Children - up to 1.5 liters. During this period, it is useful to drink sour citrus juices (grapefruit, orange, lemon). The fact is that the acidic environment kills bacteria, and the treatment process will be faster and easier.
• Follow a diet. Exclude from the diet all fried, fatty, spicy, baked foods and bakery products. Dramatically reduce the use of salt and strong meat broths.
• If all recommendations are followed, the treatment will take about 2 weeks. But a complete cure occurs after 6-7 weeks. Therefore, you can not stop drinking medicines. You need to complete the full course of treatment as prescribed by the doctor.

Symptoms, diagnosis and

According to statistics, about 20% of the world's population suffers from chronic pyelonephritis. It is an inflammatory disease of the kidneys that can develop from acute pyelonephritis, but mostly occurs as a separate disease.

Symptoms of chronic inflammation of the kidneys:

• frequent urination;
• an unreasonable increase in temperature not higher than 38 ° C, and usually in the evenings;
• slight swelling of the legs at the end of the day;
• slight swelling of the face in the morning;
• aching pain in the lower back;
• severe fatigue, often for no reason;
• increased blood pressure.

Blood and urine tests can confirm the diagnosis. In the general analysis of blood there will be low hemoglobin, and in the analysis of urine - increased leukocytes and bacteriuria. In a chronic disease, doing an ultrasound of the kidneys does not make sense - it will not show anything. It is important to understand that only a doctor can make a diagnosis. Self-medication is not worth it.

In chronic pyelonephritis, you can be treated at home, but only if the temperature and blood pressure do not rise, there is no nausea and vomiting, acute pain and suppuration. For treatment, the doctor must prescribe antibiotics and uroseptics. Therapeutic treatment lasts at least 14 days.

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During treatment, as in the case of acute inflammation, it is worth following the regimen:

In the case of a chronic disease, it will help and ethnoscience. It is worth drinking kidney herbs. Phytotherapy course - 2 times a year (in autumn and spring). Therapeutic effect will also provide sanatorium treatment with mineral waters.

The main thing in the treatment of pyelonephritis is to identify the disease in time. In addition, in the future it is important not to overcool, drink plenty of fluids and maintain hygiene.

The disease has no age restrictions, but there are groups of people who most often suffer from pyelonephritis: girls aged 18 to 30 years, older men and children under 7 years old.

To date, doctors distinguish 2 forms of the disease: acute and chronic. Each of them has its own symptoms and treatments.

Treatment for acute form

Treatment of acute pyelonephritis is carried out exclusively inpatient. It is strictly forbidden to delay treatment, as the disease can develop into a chronic form and subsequently turn into renal failure.

The course of treatment includes the use of antibiotics and a complex of vitamins aimed at eliminating the infection and normalizing the functioning of the kidneys. It is worth emphasizing that very severe forms possibly surgery.

1. Subject to all doctor's prescriptions, the treatment process will be about 2 weeks. During this time, the main symptoms will disappear, but mild pain will remain. This does not indicate a complete recovery. The full time to get rid of the disease will be 6-7 weeks.

Treatment for the chronic form

2. The process of urination is speeded up.
3. Regular increase in temperature, but at the same time a maximum of +38 ° С. As a rule, this happens in the late afternoon.
4. Slight swelling of the legs, which appear towards the end of the day.
5. Swelling on the face in the morning.
6. Regular back pain.
7. The manifestation of constant severe fatigue.
8. Elevated blood pressure.

Diagnosis is carried out in the same way as in the acute form of the disease. Urine and blood tests are carried out. A blood test in case of illness shows low level hemoglobin, and urine - an increase in leukocytes. As for ultrasound, it does not make sense to do it in the chronic form, since this species examination will show absolutely nothing. Do not forget that the disease is very serious, so self-medication is strictly prohibited. Only a doctor can make a diagnosis and prescribe a course of treatment.

Clinical recommendations for the treatment of pyelonephritis depend primarily on the form of the disease, which is an inflammatory process in the kidneys. To the main factors that cause the manifestation this disease, include: urolithiasis, violations of the structure of the urinary canals, renal colic, adenoma, etc.

The acute form of the disease develops as a result of exposure to certain infections. The development of the disease occurs in the shortest possible time, sometimes the process takes only a few hours. The main symptoms include the following:

9. manifestation of the strong pain during urination.
10. An increase in blood pressure.

In the case of such manifestations of the disease, it is strictly forbidden to engage in any methods of self-treatment. You should immediately consult a doctor. To diagnose the disease, the doctor should immediately prescribe urine and blood tests, ultrasound of the kidneys. In rare cases, an MRI is ordered.

The first few days of treatment should take place exclusively in bed. Doctors often forbid even going to the toilet. It is in this connection that the factor of inpatient treatment is important.

11. Avoid hypothermia. The patient must always be exclusively in a warm room.
12. Increasing the daily amount of liquid consumed. For adults - up to 2 liters, for children - up to 1.5 liters. Special attention should be given to citrus juices. This is due to the fact that the acid contained in them helps to fight bacteria and has a positive effect on the healing process.
13. Compliance with a certain diet. It is mandatory to exclude from the diet all fried, fatty, spicy and baked foods, bread. In addition, it is worth greatly reducing the amount of salt consumed, as it retains water.

These are the main characteristics and ways of treatment acute form kidney disease.

Statistics say that about 20% of the world's population suffers from chronic kidney disease. This form can develop both from acute pyelonephritis and be a separate type of disease.

Symptoms of a chronic illness include:

With chronic pyelonephritis, it is allowed to carry out a course of treatment at home, provided that there is no high blood pressure, vomiting, nausea, acute pain and suppuration. In the process of treatment, it is mandatory to comply with bed rest, diet and therapy prescribed by the doctor. The general course of therapeutic treatment is 2 weeks.

Pyelonephritis is a serious disease, and if you do not resort to treatment in time or aggravate the situation with self-medication, then the disease can develop into more severe stages and have an extremely negative impact on the overall level of human health. It is necessary to carry out treatment only on the recommendations of a doctor, observing regular examinations.

Pyelonephritis in children

Pyelonephritis is a simplified term for tubulointerstitial infectious nephritis. inflammatory process flowing in the pyelocaliceal system of the kidneys, tubules and tissues of the organ.

Pyelonephritis is detected in girls and boys with the same frequency when it comes to newborns. but when it comes to identifying pyelonephritis in a child after a year, girls are more likely to suffer from its manifestations, which is associated with anatomy.

There are different reasons pyelonephritis in children - inflammation begins with an attack of viruses, bacteria, fungi or protozoa. The main causative agent in this disease is Escherichia coli, the next most common causes of occurrence. Staphylococcus aureus, proteus, viruses. Chronic illness may occur due to several pathogens at once. Doctors talk about three ways pathogens enter the kidneys:

hematogenous - in this situation, the infection in infants moves to the kidneys with blood from other foci of infection. More often in a newborn, pyelonephritis begins after pneumonia, otitis media and other organs, even if they are located far from the kidneys. In children older than 3 years, the hematogenous route of infection is possible with sepsis, bacterial endocarditis and other severe infections; lymphogenous - according to the wording. the development of the infectious process is associated with the entry of pathogenic microorganisms into the kidneys through the lymphatic system. In a healthy body, lymph moves from the kidneys to the intestines, and there is no infection with this direction. If the lymph stagnates with diarrhea, constipation, dysbacteriosis, then the kidneys can be affected by the intestinal microflora; ascending - in this case, microorganisms rise from the anus, Bladder or urethra baby to the kidneys. More often this option is detected in girls after a year.

There are some risk factors. which increase the risk of developing pyelonephritis in infants and older children. The urinary tract is not sterile, they are in contact with the external environment, and therefore, children from an early age are at risk of harmful microorganisms entering them. If the local and general defenses of the child are strong enough, then his parents are unlikely to have to find out what pyelonephritis is. There are two main groups of factors predisposing to inflammation in the kidneys:

depending on the microorganism - the infectivity of the virus, its resistance and aggressiveness; dependent on the macroorganism (child) - kidney stones, crystalluria, poor urine outflow due to the abnormal structure of the urinary organs.

Other factors provoking pyelonephritis in children from 2 years to 3 years of age:

In Russia, the classification of pyelonephritis in children is carried out according to different features. In children aged 2 years and older, a kidney infection can occur in the following forms:

primary pyelonephritis. It is characterized by the absence of predisposing factors; secondary pyelonephritis in children. Occurs due to the abnormal structure and impaired functions of the urinary organs (obstructive pyelonephritis) or due to dysmetabolic disorders (non-obstructive pyelonephritis); acute pyelonephritis in children. After 1-2 months, the child recovers, which confirms laboratory examination; chronic pyelonephritis in children. The process lasts over 6 months, during which time relapses occur a couple of times. In turn, secondary chronic pyelonephritis is latent and recurrent. The first option is very rare, more often this diagnosis is associated with an erroneous opinion of the doctor, when the child does not have pyelonephritis, but an infection of the lower respiratory tract or other pathologies.

Symptoms of acute pyelonephritis

It is impossible to describe acute pyelonephritis in children with a specific list of symptoms, since the signs of pyelonephritis differ depending on the severity of the course of the disease, the age of the baby, the presence of other pathologies, etc. If the doctor knows how pyelonephritis occurs in children, classification will help him identify the type of disease, identify symptoms and treatment . make a prediction. The main symptoms of pyelonephritis in children:

the temperature rises to 38 degrees and above. Sometimes this is the only symptom that indicates that something is happening in the child's body; drowsiness, lethargy, vomiting, loss of appetite and other symptoms that indicate intoxication of the body. The younger the children, the brighter these signs appear; the skin becomes gray, under the eyes - blue circles; pain in the lower back or abdomen. Babies can't tell exactly where it hurts, but they often point to their navel. Children over 4 years old point to the lower back, lower abdomen and side. The pains are pulling in nature, decrease with warming; impaired urination is a symptom that may not manifest itself. Sometimes pyelonephritis in children is manifested by rare or frequent urination compared to the usual state, sometimes emptying the bladder causes discomfort or pain; eyelids and face swell in the morning, but not much; urine becomes cloudy, may acquire an unpleasant odor.

Slightly different pyelonephritis manifests itself in children up to a year. Newborns and infants are weakened, so their pathology causes vivid signs of intoxication:

the temperature rises above 39 degrees, can provoke convulsions; regurgitation and vomiting; sluggish breast sucking or refusal to feed; the skin turns pale, the nasolabial triangle turns blue; losing weight or stopping weight gain; the skin becomes dry and flabby due to dehydration.

Signs of chronic pyelonephritis

Chronic pathology is characterized by the alternation of calm periods without any manifestations with exacerbations, when pyelonephritis in newborns is accompanied by the same symptoms as in the acute form of pathology.

If a child is ill with a chronic form of pyelonephritis for a long time, at school age his academic performance will decrease, he will quickly get tired, get irritated over trifles. That is why it is so important in children. the main measures of which are timely diagnosis and treatment, prevention of complications.

Pyelonephritis, which develops in a child's body from an early age, leads to a delay in physical and psychomotor development.

How is pyelonephritis diagnosed?

To confirm or refute the suspicions, the doctor prescribes the diagnosis of pyelonephritis in children. which includes methods of instrumental and laboratory research. The following diagnostic measures will be required:

general clinical analysis of urine. May show an increase in leukocytes, the presence of pus and bacteria, single erythrocytes, a small amount of proteins; cumulative samples. Reveal leukocyturia; urine is given for sterility (the causative agent of inflammation is detected) and the sensitivity of pathogenic microorganisms to antibacterial drugs; general clinical blood test. Detects an infectious process by the presence of leukocytosis, anemia, accelerated ESR; biochemical analysis. In the blood, the main substances are determined, with acute pyelonephritis reveal increased C-reactive protein, in chronic - an increase in creatinine and urea, a decrease in total protein; urine biochemistry. The work of the kidneys is assessed using the Zimnitsky test, violations are confirmed by the level of urea and creatinine in the blood; measurement of blood pressure is carried out in children daily, regardless of the form of pyelonephritis. In the acute form, the pressure is normal, in the chronic form it may increase with renal failure; Ultrasound and X-ray contrast studies of the organs of the urinary system, which determine anomalies in the structure of organs; according to the doctor's prescription, other measures are taken to clarify the diagnosis - dopplerography, uloflowmetry, MRI, CT, scintigraphy, etc.

Complications of pyelonephritis

Every parent should know how dangerous pyelonephritis is. and take timely action if the child has suspicious symptoms.

Complications of pyelonephritis in children are associated with the spread of infection throughout the body, which leads to purulent processes(urosepsis, paranephritis, abscess, etc.).

These are the consequences of acute pyelonephritis. As for the chronic form, its complications are manifested by chronic renal failure, arterial hypertension.

How is acute pyelonephritis treated?

Treatment of acute pyelonephritis in children is carried out in a hospital, and it is advisable to immediately place the patients admitted to urology or nephrology. In a hospital setting, doctors will accurately select how to treat pathology, control the dynamics of tests, and conduct research. Parents cannot independently decide how to treat pyelonephritis in children. since this is a serious pathology requiring medical supervision. For example, herbal medicine, beloved by many, can only be an additional help to the main treatment; you cannot rely solely on compresses and herbal teas.

At the first suspicion of pyelonephritis in children, the symptoms of treatment should be entrusted to an experienced urologist, nephrologist. The child is shown bed rest if there is no temperature and sharp pains- you can walk in the ward, then as the condition improves, the walks are extended, the distance increases up to the territory near the hospital.

When pyelonephritis is detected in children, treatment is necessarily based on a therapeutic diet. The diet is dominated by vegetable-protein products that correct metabolic disorders and do not overload the kidneys. Spices, smoked meats, spicy and fatty dishes are excluded. The child is shown diet No. 5 according to Pevzner, the amount of salt can not be limited, but the baby should drink 50% more fluids than recommended for age. If acute pyelonephritis is accompanied by an obstructive phenomenon and kidney function is impaired, then the intake of water and salt is limited.

Antibiotics are prescribed in 2 stages. Initially, while the result of urine for sterility is ready, the doctor prescribes antibacterial drugs at random, selecting those that are active against pathogens that often provoke infectious diseases of the urinary system. Could it be cephalosporins? latest generations protected by penicillins. As soon as a urine test is obtained to identify the pathogen and its sensitivity, therapy can be adjusted as necessary. The course of treatment lasts 4 weeks, and every week the antibiotic is replaced by another so that the microorganisms do not get used to it. For disinfection of the ureters, uroantiseptics are prescribed for 2 weeks. In addition to the listed drugs, painkillers and antipyretics, antioxidants, NSAIDs can be prescribed. In the hospital, the treatment of pyelonephritis in children lasts 4 weeks, followed by discharge and prevention of pyelonephritis in children.

After discharge, once a month, you need to take a urine test, once every six months, do an ultrasound of the kidneys. To prevent pyelonephritis in a child, herbal medicine is prescribed in the future - tea from lingonberry leaves, kanefron, etc.

For the next 5 years, the child remains registered, after which it can be removed if during this time there were no relapses of pyelonephritis and antibiotics, uroseptics for inflammation of the urinary tract were not taken.

Treatment of chronic pyelonephritis

In a one-year-old baby and older children, relapses of chronic pyelonephritis are treated in a hospital using the same techniques that are used to cure acute pyelonephritis in infants. During the period of remission, the child can be planned to be admitted to a hospital for a comprehensive examination and clarification of the causes of the disease. This will help you choose drugs that prevent relapses. Identification of the cause of chronic pyelonephritis has great importance, because only after its elimination can we talk about the elimination of pathology.

Taking into account what caused the infectious and inflammatory process in the kidneys, treatment is prescribed:

surgical (with anomalies with obstruction, vesicoureteral reflux); diet therapy (with dysmetabolic nephropathy); psychotherapy and medications for neurogenic bladder dysfunction.

During remission, you need to take up anti-relapse prevention - take courses of antibacterial and uroseptic drugs, herbal medicine. The doctor will prescribe a medication regimen and indicate when to take breaks.

A child diagnosed with chronic pyelonephritis is observed by a pediatrician and a nephrologist, scheduled examinations are recommended before being transferred to an adult clinic.

Treatment of chronic pyelonephritis in women and men (clinical recommendations)

Chronic pyelonephritis - sluggish, periodically aggravated bacterial inflammation of the interstitium of the kidney, leading to irreversible changes in the pelvicalyceal system, followed by sclerosis of the parenchyma and wrinkling of the kidney.

By localization chronic pyelonephritis may be unilateral or bilateral. affecting one or both kidneys. Usually found bilateral chronic pyelonephritis.

Often chronic pyelonephritis (CP) is the result of improper treatment acute pyelonephritis (OP) .

In a significant proportion of patients who have undergone acute pyelonephritis or exacerbation chronic pyelonephritis, within 3 months after the exacerbation, a relapse occurs chronic pyelonephritis .

Prevalence rate chronic pyelonephritis in Russia is 18-20 cases per 1000 people, while in other countries acute pyelonephritis is cured completely without going into chronic .

Although complete curability has been proven throughout the world acute pyelonephritis in 99% of cases, and the diagnosis "chronic pyelonephritis" is simply missing from foreign classifications, mortality from pyelonephritis in Russia, according to the causes of death, it ranges from 8 to 20% in different regions.

Low effectiveness of treatment acute and chronic pyelonephritis associated with the lack of timely conduct by doctors general practice rapid tests using test strips, prescription of long unreasonable examinations, incorrect empirical prescription of antibiotics, visits to non-specialist specialists, attempts at self-treatment and late seeking medical help.

Types of chronic pyelonephritis

Chronic pyelonephritis - ICD-10 code

• №11.0 Non-obstructive chronic pyelonephritis associated with reflux
• №11.1 Chronic obstructive pyelonephritis
• №20.9 Calculous pyelonephritis

According to the conditions of occurrence, chronic pyelonephritis is divided into:

• primary chronic pyelonephritis, developing in an intact kidney (without developmental anomalies and diagnosed disorders of urinary tract urodynamics);
• secondary chronic pyelonephritis. arising on the background of diseases that violate the passage of urine.

Chronic pyelonephritis in women

Women suffer from pyelonephritis 2-5 times more often than men, which is associated with anatomical features organism. In women, the urethra is much shorter than in men, so bacteria can easily penetrate through it from the outside into the bladder and from there through the ureters can enter the kidneys.

development chronic pyelonephritis For women, factors such as:

• pregnancy;
• gynecological diseases that violate the outflow of urine;
• the presence of vaginal infections;
• use of vaginal contraceptives;
• unprotected intercourse;
• hormonal changes in the premenopausal and postmenopausal periods;
• neurogenic bladder.

Chronic pyelonephritis in men

In men chronic pyelonephritis often associated with difficult working conditions, hypothermia, poor personal hygiene, various diseases that interfere with the outflow of urine (prostate adenoma, urolithiasis, sexually transmitted diseases).

Causes chronic pyelonephritis men can have:

• prostatitis;
• stones in the kidneys, ureters, bladder;
• unprotected sex;
• STDs (sexually transmitted diseases);
• diabetes.

Causes of chronic pyelonephritis

In the formation of primary chronic pyelonephritis, an important role is played by the infectious agent, its virulence, as well as the nature of the body's immune response to the pathogen. The introduction of an infectious agent is possible by ascending, hematogenous or lymphogenous routes.

Most often, the infection enters the kidneys by ascending through the urethra. Normally, the presence of microflora is permissible only in the distal urethra, however, in some diseases, the normal passage of urine is disturbed and urine is thrown back from the urethra and bladder into the ureters, and from there to the kidneys.

Diseases that violate the passage of urine and cause chronic pyelonephritis:

• anomalies in the development of the kidneys and urinary tract;
• urolithiasis disease;
• strictures of the ureter of various etiologies;
• Ormond's disease (retroperitoneal sclerosis);
• vesicoureteral reflux and reflux nephropathy;
• adenoma and sclerosis of the prostate;
• sclerosis of the neck of the bladder;
• neurogenic bladder (especially hypotonic type);
• cysts and tumors of the kidney;
• neoplasms of the urinary tract;
• malignant tumors of the genital organs.

Risk factors (FR) for urinary tract infections are presented in Table 1.

Table 1. Risk factors for urinary tract infections

Chronic pyelonephritis

Treatment of pyelonephritis

Goals of treatment for pyelonephritis

• Achieving clinical and laboratory remission.
• Prevention and correction of complications.

Principles of therapy

1. Increase fluid intake for the purpose of detoxification and mechanical sanitation of the urinary tract. Water load is contraindicated if there is:

• urinary tract obstruction, postrenal acute renal failure;
• nephrotic syndrome;
• uncontrolled arterial hypertension;
• chronic heart failure, starting from the second stage IIA;
• preeclampsia in the second half of pregnancy.

2. Antimicrobial therapy is the basic treatment for pyelonephritis. The outcome of chronic pyelonephritis depends precisely on the competent prescription of antibiotics.

3. Treatment of pyelonephritis is supplemented according to indications with antispasmodics, anticoagulants (heparin) and antiplatelet agents (pentoxifylline, ticlopidine).

4. Phytotherapy is an additional, but not an independent method of treatment. It is used during the period of remission 2 times a year as a prophylactic course (spring, autumn). Use for at least 1 month, combine with antiplatelet agents. Don't get carried away with taking medicinal herbs due to their possible damaging effect on the renal tubules.

5. Physiotherapy and spa treatment of pyelonephritis. Although there is no scientific evidence of the effectiveness of these methods, nevertheless, according to a subjective assessment, they contribute to an improvement in the quality of life. This treatment pyelonephritis is used in the remission phase, using the antispasmodic effect of thermal procedures (inductothermy, UHF- or SMW-therapy, paraffin-ozocerite applications).

Antimicrobial treatment of pyelonephritis

Antimicrobial treatment of pyelonephritis continues for 14 days. Further, for 2-4 weeks, it is advisable to prescribe decoctions of uroseptic herbs (bearberry, field horsetail, lingonberry leaf, cranberries, juniper berries, rose hips, etc.). Then treatment is stopped until the next exacerbation.

The criteria for the effectiveness of therapy are the general well-being of the patient, body temperature, the degree of leukocyturia, bacteriuria, and the functional state of the kidneys.

If the bacteria in the urine turned out to be sensitive to the prescribed antibiotic, then the decrease in temperature and the sterility of the urine occurs 1-3 days after the start of treatment; leukocyturia disappears after 5-10 days, the acceleration of ESR can persist for up to 2-3 weeks.

The lack of effect is primarily due to antibiotic resistance. Do not use ampicillin, co-trimaxosole (biseptol), cephalosporins of the first generation and, especially, nitrofurans due to the presence of high resistance of microorganisms to them. The first generation fluoroquinolones are the drug of choice.

First line antimicrobials

• What is chronic pyelonephritis
• Treatment of chronic pyelonephritis
• Prevention of chronic pyelonephritis

What is chronic pyelonephritis

Chronic pyelonephritis is the result of untreated or undiagnosed acute pyelonephritis. It is considered possible to talk about chronic pyelonephritis already in those cases when recovery after acute pyelonephritis does not occur within 2-3 months. The literature discusses the possibility of primary chronic pyelonephritis, i.e., without a history of acute pyelonephritis. This explains, in particular, the fact that chronic pyelonephritis is more common than acute. However, this opinion is not sufficiently substantiated and is not recognized by everyone.

Pathogenesis (what happens?) during Chronic pyelonephritis

In a pathomorphological study in patients with chronic pyelonephritis, a decrease in one or both kidneys is macroscopically detected, as a result of which, in most cases, they differ in size and weight. Their surface is uneven, with areas of retraction (at the site of cicatricial changes) and protrusion (at the site of unaffected tissue), often coarsely bumpy. The fibrous capsule is thickened, it is difficult to separate from the renal tissue due to numerous adhesions. On the surface of the incision of the kidney, areas of scar tissue of a grayish color are visible. In the advanced stage of pyelonephritis, the mass of the kidney decreases to 40-60 g. The cups and pelvis are somewhat dilated, their walls are thickened, and the mucosa is sclerosed.

A characteristic morphological feature of chronic pyelonephritis, as well as acute, is focality and polymorphism of renal tissue lesions: along with areas of healthy tissue, there are foci inflammatory infiltration and zones of cicatricial changes. The inflammatory process primarily affects the interstitial tissue, then the renal tubules are involved in the pathological process, the atrophy and death of which occurs due to infiltration and sclerosis of the interstitial tissue. And first, the distal and then the proximal parts of the tubules are damaged and die. The glomeruli are involved in the pathological process only in the late (terminal) stage of the disease; therefore, the decrease in glomerular filtration occurs much later than the development of concentration deficiency. Relatively early, pathological changes develop in the vessels and manifest themselves in the form of endarteritis, hyperplasia of the middle membrane and sclerosis of arterioles. These changes lead to a decrease in renal blood flow and the occurrence of arterial hypertension.

Morphological changes in the kidneys usually increase slowly, which determines the long-term duration of this disease. Due to the earliest and predominant damage to the tubules and a decrease in the concentration ability of the kidneys, diuresis persists for many years with a low, and then with a monotonous relative density of urine (hypo- and isohyposthenuria). Glomerular filtration persists for a long time normal level and decreases only in the late stage of the disease. Therefore, compared with chronic glomerulonephritis, the prognosis in patients with chronic pyelonephritis in relation to life expectancy is more favorable.

Symptoms of chronic pyelonephritis

Current and clinical picture Chronic pyelonephritis depends on many factors, including the localization of the inflammatory process in one or both kidneys (unilateral or bilateral), the prevalence of the pathological process, the presence or absence of an obstruction to the flow of urine in the urinary tract, the effectiveness of previous treatment, the possibility of concomitant diseases.

Clinical and laboratory signs of chronic pyelonephritis are most pronounced in the phase of exacerbation of the disease, and insignificant during remission, especially in patients with latent pyelonephritis. In primary pyelonephritis, the symptoms of the disease are less pronounced than in secondary pyelonephritis. Exacerbation of chronic pyelonephritis may resemble acute pyelonephritis and be accompanied by fever, sometimes up to 38-39 ° C, pain in the lumbar region (on one or both sides), dysuric phenomena, deterioration in general condition, loss of appetite, headache, often (more often in children ) abdominal pain, nausea and vomiting.

An objective examination of the patient can be noted puffiness of the face, pastosity or swelling of the eyelids, often under the eyes, especially in the morning after sleep, pallor skin; positive (although not always) Pasternatsky's symptom on one side (left or right) or on both sides with bilateral pyelonephritis. In the blood, leukocytosis and an increase in ESR are detected, the severity of which depends on the activity of the inflammatory process in the kidneys. Leukocyturia, bacteriuria, proteinuria appear or increase (usually not exceeding 1 g / l and only in some cases reaching 2.0 g or more per day), in many cases active leukocytes are detected. There is moderate or severe polyuria with hypostenuria and nocturia. The above symptoms, especially if there is a history of indications of acute pyelonephritis, makes it relatively easy, timely and correctly to determine the diagnosis of chronic pyelonephritis.

More significant diagnostic difficulties are pyelonephritis during remission, especially primary and latent course. In such patients, pain in the lumbar region is minor and intermittent, aching or pulling. Dysuric phenomena in most cases are absent or are observed occasionally and are not very pronounced. The temperature is usually normal and only sometimes (more often in the evenings) rises to subfebrile numbers (37-37.1 ° C). Proteinuria and leukocyturia are also minor and intermittent. The concentration of protein in the urine ranges from traces to 0.033-0.099 g / l. The number of leukocytes in repeated urine tests does not exceed the norm or reaches 6-8, less often 10-15 in the field of view. Active leukocytes and bacteriuria in most cases are not detected. Often there is a slight or moderate anemia, a slight increase in ESR.

With a long course of chronic pyelonephritis, patients complain of increased fatigue, decreased performance, loss of appetite, weight loss, lethargy, drowsiness, headaches periodically occur. Later, dyspeptic phenomena, dryness and peeling of the skin join. The skin acquires a peculiar grayish-yellow color with an earthy tint. The face is puffy, with constant pastiness of the eyelids; the tongue is dry and covered with a dirty brown coating, the mucous membrane of the lips and mouth is dry and rough. In 40-70% of patients with chronic pyelonephritis (V. A. Pilipenko, 1973), as the disease progresses, symptomatic arterial hypertension develops, reaching a high level in some cases, especially diastolic pressure (180/115-220/140 mm Hg) . Approximately in 20-25% of patients, arterial hypertension joins already in the initial stages (in the first years) of the disease. There is no doubt that the addition of hypertension not only changes the clinical picture of the disease, but also aggravates its course. As a consequence of hypertension, hypertrophy of the left ventricle of the heart develops, often with signs of its overload and ischemia, clinically accompanied by attacks of angina pectoris. Possible hypertensive crises with left ventricular failure, dynamic violation of cerebral circulation, and in more severe cases - with strokes and thrombosis of cerebral vessels. Symptomatic antihypertensive therapy is ineffective if the pyelonephritic genesis of arterial hypertension is not established in a timely manner and anti-inflammatory treatment is not carried out.

In the later stages of pyelonephritis, bone pain, polyneuritis, and hemorrhagic syndrome occur. Edema is not typical and is practically not observed.

For chronic pyelonephritis in general and in the later stages, polyuria is especially characteristic with the release of up to 2-3 liters or more of urine during the day. Cases of polyurine reaching 5-7 liters per day are described, which can lead to the development of hypokalemia, hyponatremia and hypochloremia; polyuria is accompanied by pollakiuria and nocturia, hypostenuria. As a result of polyuria, thirst and dry mouth appear.

The symptoms of chronic primary pyelonephritis are often so poor that the diagnosis is made very late, when signs of chronic renal failure are already observed, or when arterial hypertension is accidentally detected and its origin is tried to be established. In some cases, a peculiar complexion, dry skin and mucous membranes, taking into account complaints of an asthenic nature, make it possible to suspect chronic pyelonephritis.

Diagnosis of chronic pyelonephritis

Establishing the diagnosis of chronic pyelonephritis is based on the complex use of data from the clinical picture of the disease, the results of clinical and laboratory, biochemical, bacteriological, ultrasound, X-ray urological and radioisotope studies, and, if necessary and possible, data from a puncture biopsy of the kidney. An important role belongs to a carefully collected anamnesis. Indications in the anamnesis of past cystitis, urethritis, pyelitis, renal colic, the passage of stones, as well as anomalies in the development of the kidneys and urinary tract are always significant factors in favor of chronic pyelonephritis.

The greatest difficulties in the diagnosis of chronic pyelonephritis arise in its latent, latent course, when Clinical signs diseases are either absent, or so slightly expressed and not characteristic that they do not allow a convincing diagnosis. Therefore, the diagnosis of chronic pyelonephritis in such cases is based mainly on the results of laboratory, instrumental and other research methods. In this case, the leading role is given to the study of urine and the detection of leukocyturia, proteinuria and bacteriuria.

Proteinuria in chronic pyelonephritis, as in acute pyelonephritis, is usually insignificant and does not exceed, with rare exceptions, 1.0 g / l (usually from traces to 0.033 g / l), and the daily excretion of protein in the urine is less than 1.0 g. Leukocyturia may be varying degrees severity, but more often the number of leukocytes is 5-10, 15-20 in the field of view, rarely reaches 50-100 or more. Occasionally, isolated hyaline and granular casts are found in the urine.

In patients with a latent course of the disease, proteinuria and leukocyturia may not be present at all during a routine urinalysis in separate or several tests, so it is necessary to conduct urine tests in dynamics repeatedly, including according to Kakovsky-Addis, Nechiporenko, for active leukocytes, as well as seeding urine on the microflora and the degree of bacteriuria. If the protein content in the daily amount of urine exceeds 70-100 mg, the number of leukocytes in the sample according to Kakovsky-Addis is more than 4. 106 / day, and in the study according to Nechiporenko - more than 2.5. 106 / l, then this may speak in favor of pyelonephritis.

The diagnosis of pyelonephritis becomes more convincing if active leukocytes or Sternheimer-Malbin cells are found in the urine of patients. However, their importance should not be overestimated, since it has been established that they are formed at a low osmotic pressure of urine (200-100 mosm / l) and again turn into ordinary leukocytes with an increase in the osmotic activity of urine. Therefore, these cells may be the result of not only an active inflammatory process in the kidneys, but also the result of a low relative density of urine, which is often observed in pyelonephritis. However, if the number of active leukocytes is more than 10-25% of all leukocytes excreted in the urine, then this not only confirms the presence of pyelonephritis, but also indicates its active course (M. Ya. Ratner et al. 1977).

An equally important laboratory sign of chronic pyelonephritis is bacteriuria, exceeding 50-100 thousand in 1 ml of urine. It can be detected in various phases of this disease, but more often and more significant during the period of exacerbation. It has now been proven that the so-called physiological (or false, isolated, without inflammatory process) bacteriuria does not exist. Long-term follow-up of patients with isolated bacteriuria, without other signs of damage to the kidneys or urinary tract, showed that some of them develop a full clinical picture of pyelonephritis over time. Therefore, the terms "bacteriuria" and even more so "urinary tract infection" should be treated with caution, especially in pregnant women and children. Although isolated bacteriuria does not always lead to the development of pyelonephritis, however, to prevent it, some authors recommend treating each such patient until urine is completely sterile (I. A. Borisov, V. V. Sura, 1982).

With asymptomatic, latent and atypically occurring forms of chronic pyelonephritis, when the methods of urine examination mentioned above are not convincing enough, provocative tests (in particular, prednisone) are also used to temporarily activate the latent current inflammatory process in the kidneys.

In chronic pyelonephritis, even primary, hematuria is also possible, mainly in the form of microhematuria, which, according to V. A. Pilipenko (1973), occurs in 32.3% of cases. Some authors (M. Ya. Ratner, 1978) distinguish the hematuric form of pyelonephritis. Gross hematuria sometimes accompanies calculous pyelonephritis or develops as a result of a destructive process in the vault of the cup (fornic bleeding).

In the peripheral blood, anemia, an increase in ESR are more often detected, less often - a slight leukocytosis with a neutrophilic shift of the leukocyte formula to the left. In the proteinogram of the blood, especially in the acute phase, there are pathological changes with hypoalbuminemia, hyper-a1- and a2-globulinemia, in the late stages with hypogammaglobulinemia.

In contrast to chronic glomerulonephritis, in chronic pyelonephritis, it is not glomerular filtration that first decreases, but the concentration function of the kidneys, resulting in often observed polyuria with hypo- and isosthenuria.

Violations of electrolyte homeostasis (hypokalemia, hyponatremia, hypocalcemia), which sometimes reach significant severity, are due to polyuria and a large loss of these ions in the urine.

In the advanced stage of chronic pyelonephritis, glomerular filtration is significantly reduced, as a result, the concentration of nitrogenous wastes - urea, creatinine, residual nitrogen - increases in the blood. However, transient hyperazotemia can also occur during an exacerbation of the disease. In such cases, under the influence of successful treatment, the nitrogen excretion function of the kidneys is restored and the level of creatinine and urea in the blood is normalized. Therefore, the prognosis for the appearance of signs of chronic renal failure in patients with pyelonephritis is more favorable than in patients with chronic glomerulonephritis.

An essential role in the diagnosis of chronic pyelonephritis, especially secondary, is played by ultrasound and X-ray methods of investigation. The unequal sizes of the kidneys, the unevenness of their contours, the unusual location can be detected even on a plain radiograph and with the help of ultrasound. More detailed information about the violation of the structure and function of the kidneys, pyelocaliceal system and upper urinary tract can be obtained using excretory urography, especially infusion. The latter gives clearer results even with a significant violation of the excretory function of the kidneys. Excretory urography allows you to identify not only changes in the size and shape of the kidneys, their location, the presence of stones in the cups, pelvis or ureters, but also to judge the state of the total excretory function of the kidneys. Spasm or club-shaped expansion of the cups, a violation of their tone, deformation and expansion of the pelvis, changes in the shape and tone of the ureters, anomalies in their development, strictures, expansion, kinks, torsion and other changes testify in favor of pyelonephritis.

In the later stages of the disease, when wrinkling of the kidneys occurs, a decrease in their size (or one of them) is also detected. At this stage, the impairment of kidney function reaches a significant degree and the excretion of the contrast agent sharply slows down and decreases, and sometimes is completely absent. Therefore, with severe renal insufficiency, it is not advisable to carry out excretory urography, since contrasting of the renal tissue and urinary tract is sharply reduced or does not occur at all. In such cases, when urgently needed, resort to infusion urography or retrograde pyelography, as well as with unilateral obturation of the ureter with a violation of the outflow of urine. If the contours of the kidneys are not clearly detected during survey and excretory urography, and if a kidney tumor is suspected, pneumorethroperitoneum (pneumoren) is used, CT scan.

Substantial assistance in complex diagnostics pyelonephritis is rendered by radioisotope methods - renography and kidney scanning. However, their differential diagnostic value is relatively small compared to X-ray examination, since the dysfunction and changes in the structure of the kidneys detected with their help are nonspecific and can be observed in other kidney diseases, and renography, in addition, also gives a high percentage diagnostic errors. These methods make it possible to establish a dysfunction of one of the kidneys compared to the other and, therefore, are of great importance in the diagnosis of secondary and unilateral pyelonephritis, while in primary pyelonephritis, which is more often bilateral, their diagnostic value is small. However, in the complex diagnosis of chronic pyelonephritis, especially when, for one reason or another (allergy to a contrast agent, significant impairment of kidney function, etc.), excretory urography is impossible or contraindicated, radioisotope research methods can be of great help.

For the diagnosis of unilateral pyelonephritis, as well as to clarify the genesis of arterial hypertension in large diagnostic centers, renal angiography is also used.

Finally, if it is still not possible to accurately establish the diagnosis, intravital puncture biopsy of the kidney is indicated. However, it should be borne in mind that this method does not always allow to confirm or exclude the diagnosis of pyelonephritis. According to I. A. Borisov and V. V. Sura (1982), with the help of a puncture biopsy, the diagnosis of pyelonephritis can be confirmed only in 70% of cases. This is explained by the fact that in pyelonephritis, pathological changes in the renal tissue are focal in nature: healthy tissue is located next to the areas of inflammatory infiltration, the penetration of a puncture needle into which gives negative results and cannot confirm the diagnosis of pyelonephritis if it is unquestionably present. Therefore, only positive results puncture biopsy, i.e. confirming the diagnosis of pyelonephritis.

Chronic pyelonephritis must be differentiated primarily from chronic glomerulonephritis, renal amyloidosis, diabetic glomerulosclerosis and hypertension.

Amyloidosis of the kidneys in the initial stage, manifested only by slight proteinuria and very poor urinary sediment, can simulate a latent form of chronic pyelonephritis. However, unlike pyelonephritis, leukocyturia is absent in amyloidosis, active leukocytes and bacteriuria are not detected, the concentration function of the kidneys remains at a normal level, there are no radiographic signs of pyelonephritis (the kidneys are the same, of normal size or somewhat enlarged). In addition, secondary amyloidosis is characterized by the presence of long-term chronic diseases, more often purulent-inflammatory.

Diabetic glomerulosclerosis develops in patients with diabetes, especially with its severe course and long duration of the disease. At the same time, there are other signs of diabetic angiopathy (changes in the vessels of the retina, lower extremities, polyneuritis, etc.). There are no dysuria, leukocyturia, bacteriuria and radiological signs pyelonephritis.

Chronic pyelonephritis with symptomatic hypertension, especially with a latent course, is often mistakenly assessed as hypertension. Differential diagnosis of these diseases presents great difficulties, especially in the terminal stage.

If from history or medical records it is possible to establish that changes in the urine (leukocyturia, proteinuria) preceded (sometimes for many years) the appearance of hypertension, or cystitis, urethritis were observed long before its development, renal colic, stones were found in the urinary tract, then the symptomatic origin of hypertension as a consequence of pyelonephritis is usually not in doubt. In the absence of such indications, it should be taken into account that hypertension in patients with chronic pyelonephritis is characterized by higher diastolic pressure, stability, insignificant and unstable effectiveness of antihypertensive drugs and a significant increase in their effectiveness if they are used in combination with antimicrobial agents. Sometimes, at the beginning of the development of hypertension, only anti-inflammatory therapy is sufficient, which, without antihypertensive drugs, leads to a decrease or even stable normalization of blood pressure. Often you have to resort to the study of urine according to Kakovsky-Addis, for active leukocytes, urine culture for microflora and the degree of bacteriuria, pay attention to the possibility of unmotivated anemia, an increase in ESR, a decrease in the relative density of urine in the Zimnitsky sample, which are characteristic of pyelonephritis.

In favor of pyelonephritis, some data from ultrasound and excretory urography (deformation of the cups and pelvis, stricture or atony of the ureters, nephroptosis, unequal sizes of the kidneys, the presence of calculi, etc.), radioisotope renography (decreased function of one kidney with preserved function of the other) and renal angiography (narrowing, deformation and reduction in the number of small and medium-sized arteries). If the diagnosis is in doubt even after all the above methods of research, it is necessary (if possible and in the absence of contraindications) to resort to a puncture biopsy of the kidneys.

Treatment of chronic pyelonephritis

It should be comprehensive, individual and include a regimen, diet, medications and measures aimed at eliminating the causes that prevent the normal passage of urine.

Patients with chronic pyelonephritis during the period of exacerbation of the disease need inpatient treatment. At the same time, as in acute pyelonephritis, it is advisable to hospitalize patients with secondary pyelonephritis in urological departments, and with primary - in therapeutic or specialized nephrological departments. They are prescribed bed rest, the duration of which depends on the severity of the clinical symptoms of the disease and their dynamics under the influence of the treatment.

Mandatory component complex therapy is a diet that provides for the exclusion from the diet of spicy dishes, rich soups, various flavoring seasonings, strong coffee. Food should be sufficiently high-calorie (2000-2500 kcal), contain the physiologically necessary amount of basic ingredients (proteins, fats, carbohydrates), well fortified. These requirements are best met by a dairy-vegetarian diet, as well as meat, boiled fish. In the daily diet, it is advisable to include dishes from vegetables (potatoes, carrots, cabbage, beets) and fruits (apples, plums, apricots, raisins, figs), rich in potassium and vitamins C, P, group B, milk and dairy products, eggs.

Since with rare exceptions, edema is absent in chronic pyelonephritis, the liquid can be taken without restriction. It is desirable to use it in the form of various fortified drinks, juices, fruit drinks, compotes, kissels, as well as mineral water, cranberry juice is especially useful (up to 1.5-2 liters per day). Fluid restriction is necessary in cases where an exacerbation of the disease is accompanied by a violation of the outflow of urine or arterial hypertension, which requires a more severe restriction of salt (up to 4-6 g per day), while in the absence of hypertension during an exacerbation, up to 6-8 g is necessary, and with a latent course - up to 8-10 g. Patients with anemia are shown foods rich in iron and cobalt (apples, pomegranates, strawberries, strawberries, etc.). In all forms and at any stage of pyelonephritis, it is recommended to include watermelons, melons, pumpkins in the diet, which have a diuretic effect and help cleanse the urinary tract from microbes, mucus, and small stones.

Of decisive importance in the treatment of chronic pyelonephritis, as well as acute, belongs to antibiotic therapy, the basic principle of which is the early and long-term administration of antimicrobial agents in strict accordance with the sensitivity of the microflora sown from urine to them, alternation antibacterial drugs or their combined use. Antibacterial therapy is ineffective if it is started late, is not carried out actively enough, without taking into account the sensitivity of the microflora, and if the obstacles to the normal passage of urine are not eliminated.

In the late stage of pyelonephritis, due to the development of sclerotic changes in the kidneys, a decrease in renal blood flow and glomerular filtration, it is not possible to achieve the required concentration of antibacterial drugs in the renal tissue, and the effectiveness of the latter drops markedly even at high doses. In turn, due to a violation of the excretory function of the kidneys, there is a danger of cumulation of antibiotics introduced into the body and the risk of severe side effects increases, especially when large doses are prescribed. With late-started antibiotic therapy and insufficiently active treatment, it becomes possible to develop antibiotic-resistant strains of microbes and microbial associations with different susceptibility to the same antimicrobial drug.

For the treatment of pyelonephritis, antibiotics, sulfonamides, nitrofurans, nalidixic acid, b-NOC, bactrim (biseptol, septrin) are used as antimicrobial agents. Preference is given to the drug to which the microflora is sensitive and which is well tolerated by patients. Penicillin drugs have the least nephrotoxicity, especially semi-synthetic penicillins (oxacillin, ampicillin, etc.), oleandomycin, erythromycin, levomycetin, cephalosporins (kefzol, tseporin). Nitrofurans, nalidixic acid (negram, nevigramon), 5-NOC are distinguished by slight nephrotoxicity. Aminoglycosides (kanamycin, colimycin, gentamicin) have high nephrotoxicity, which should be prescribed only in severe cases and for a short period (5-8 days), in the absence of the effect of other antibiotics to which the microflora turned out to be resistant.

When prescribing antibiotics, it is also necessary to take into account the dependence of their activity on urine pH. For example, gentamicin and erythromycin are most effective in alkaline urine (pH 7.5-8.0), therefore, when prescribing them, a dairy-vegetarian diet is recommended, the addition of alkalis ( baking soda and others), the use of alkaline mineral water (Borjomi, etc.). Ampicillin and 5-NOC are most active at pH 5.0-5.5. Cephalosporins, tetracyclines, chloramphenicol are effective in both alkaline and acidic urine reactions (ranging from 2.0 to 8.5-9.0).

During the period of exacerbation, antibiotic therapy is carried out for 4-8 weeks - until the elimination of clinical and laboratory manifestations of the activity of the inflammatory process. In severe cases, they resort to various combinations of antibacterial drugs (an antibiotic with sulfonamides or furagin, 5-NOC, or a combination of all together); shows their parenteral administration, often intravenously and in large doses. An effective combination of penicillin and its semi-synthetic analogues with nitrofuran derivatives (furagin, furadonin) and sulfonamides (urosulfan, sulfadimethoxine). Nalidixic acid preparations can be combined with all antimicrobial agents. To them, the least resistant strains of microbes are observed. Effective, for example, the combination of carbenicillin or aminoglycosides with nalidixic acid, the combination of gentamicin with cephalosporins (preferably with kefzol), cephalosporins and nitrofurans; penicillin and erythromycin, as well as antibiotics with 5-NOC. The latter is currently considered one of the most active uroseptics with a wide spectrum of action. Levomycetin succinate 0.5 g 3 times a day intramuscularly is very effective, especially with gram-negative flora. Gentamycin (garamycin) finds widespread use. It has a bactericidal effect on coli and other Gram-negative bacteria; it is also active against gram-positive microbes, in particular against penicillinase-forming staphylococcus aureus and b-hemolytic streptococcus. The high antibacterial effect of gentamicin is due to the fact that 90% of it is excreted unchanged by the kidneys, and therefore a high concentration of this drug is created in the urine, which is 5-10 times higher than the bactericidal one. It is prescribed 40-80 mg (1-2 ml) 2-3 times a day intramuscularly or intravenously for 5-8 days.

The number of antibacterial drugs currently used for the treatment of pyelonephritis is large and increases every year, so it is not possible and necessary to dwell on the characteristics and effectiveness of each of them. The doctor prescribes this or that drug individually, taking into account the above basic principles of therapy for chronic pyelonephritis.

The criteria for the effectiveness of the treatment are the normalization of temperature, the disappearance of dysuric phenomena, the return to normal values ​​of peripheral blood (leukocyte count, ESR), the persistent absence or at least a noticeable decrease in proteinuria, leukocyturia and bacteriuria.

Since even after successful treatment, frequent (up to 60-80%) relapses of the disease are observed, it is generally accepted to carry out many months of anti-relapse therapy. It is necessary to prescribe various antimicrobial drugs, sequentially alternating them, taking into account the sensitivity of the microflora to them and under control of the dynamics of leukocyturia, bacteriuria and proteinuria. There is still no consensus on the duration of such treatment (from 6 months to 1-2 years).

Various schemes of intermittent treatment on an outpatient basis have been proposed. The most widely used is the scheme, according to which, for 7-10 days of each month, various antimicrobial agents are alternately prescribed (an antibiotic, for example, levomycetin, 0.5 g 4 times a day, next month, a sulfanilamide drug, for example, urosulfan or etazol, in subsequent months - furagin, nevigramon, 5-NOC, changing every month). Then the treatment cycle is repeated.

In the intervals between medications, it is recommended to take decoctions or infusions of herbs that have a diuretic and antiseptic effect (cranberry juice, rosehip broth, horsetail grass, juniper fruits, birch leaves, bearberry, lingonberry leaf, celandine leaves and stems, etc.). For the same purpose, you can use nikodin (within 2-3 weeks), which has moderate antibacterial activity, especially with concomitant cholecystitis.

In some cases, the treatment of chronic pyelonephritis with antibacterial agents may be accompanied by allergic and other side effects, and therefore, to reduce or prevent them, antihistamines(diphenhydramine, pipolfen, tavegil, etc.). Sometimes you have to completely abandon them and resort to cylotropin, urotropin, salol. At long-term treatment it is advisable to prescribe vitamins with antibiotics.

Patients with arterial hypertension are shown antihypertensive drugs (reserpine, adelfan, hemiton, clonidine, dopegyt, etc.) in combination with saluretics (hypothiazid, furosemide, triampur, etc.). In the presence of anemia, in addition to iron preparations, vitamin B12, folic acid, anabolic hormones, transfusion of erythrocyte mass, whole blood is indicated (with significant and persistent anemia).

According to the indications, complex therapy includes cardiac glycosides - corglicon, strophanthin, celanide, digoxin, etc.

In patients with secondary pyelonephritis, along with conservative therapy, they often resort to surgical methods of treatment in order to eliminate the cause of urinary stasis (especially with calculous pyelonephritis, prostate adenoma, etc.).

An important place in the complex therapy of chronic pyelonephritis is sanatorium treatment, mainly in patients with secondary (calculous) pyelonephritis after surgery for the removal of stones. The most indicated stay in balneo-drinking sanatoriums is Truskavets, Zheleznovodsk, Sairme, Berezovskie Mineralnye Vody. Plentiful drink mineral waters helps to reduce the inflammatory process in the kidneys and urinary tract, "wash out" of them mucus, pus, microbes and small stones, improves general state sick.

Patients with high arterial hypertension and severe anemia, with symptoms of renal failure, spa treatment is contraindicated. Patients with chronic pyelonephritis should not be sent to climatic resorts, since the effect of this is usually not observed.

Prevention of chronic pyelonephritis

Measures for the prevention of chronic pyelonephritis are the timely and thorough treatment of patients with acute pyelonephritis, in dispensary observation and examination of this contingent of patients, their correct employment, as well as in the elimination of the causes that impede the normal outflow of urine, in the treatment of acute diseases of the bladder and urinary tract; in the rehabilitation of chronic foci of infection.

In chronic primary pyelonephritis, the recommendations for the employment of patients are the same as for chronic glomerulonephritis, i.e., patients can perform work that is not associated with great physical and nervous stress, with the possibility of hypothermia, prolonged stay on their feet, in night shifts, in hot workshops.

Diet, diet are the same as in acute pyelonephritis. In the presence of symptomatic hypertension, more severe salt restriction is required, as well as some fluid restriction, especially in cases where there is edema or a tendency to edema. In order to prevent exacerbations of pyelonephritis and its progression, various schemes for long-term therapy of this disease have been proposed.

In secondary acute or chronic pyelonephritis, the success of both inpatient and long-term outpatient treatment largely depends on the elimination of the causes that lead to impaired urine outflow (calculi, ureteral strictures, prostate adenoma, etc.). Patients should be under the supervision of a urologist or a nephrologist (therapist) and a urologist.

In the prevention of recurrence of chronic pyelonephritis, its further progression and the development of chronic renal failure, timely detection and careful treatment of hidden or obvious foci of infection, as well as intercurrent diseases, are important.

Patients who have had acute pyelonephritis after discharge from the hospital should be registered with the dispensary and observed for at least one year, subject to normal urine tests and in the absence of bacteriuria. If proteinuria, leukocyturia, bacteriuria persist or periodically appear, the dispensary observation period is increased to three years from the onset of the disease, and then, in the absence of a complete treatment effect, patients are transferred to a group with chronic pyelonephritis.

Patients with chronic primary pyelonephritis need constant long-term dispensary observation with periodic inpatient treatment in case of exacerbation of the disease or an increasing decline in kidney function.

In acute pyelonephritis after a course of treatment in a hospital, patients are subject to a dispensary examination once every two weeks in the first two months, and then once every one to two months during the year. Urine tests are mandatory - general, according to Nechiporenko, for active leukocytes, for the degree of bacteriuria, for microflora and its sensitivity to antibacterial agents, as well as a general blood test. Once every 6 months, the blood is examined for the content of urea, creatinine, electrolytes, total protein and protein fractions, determine glomerular filtration, urinalysis according to Zimnitsky, if necessary, a consultation with a urologist and X-ray urological examinations are indicated.

In patients with chronic pyelonephritis in the inactive phase, the same amount of research as in acute pyelonephritis should be carried out once every six months.

With the appearance of signs of chronic renal failure, the terms of dispensary examinations and examinations are significantly reduced as it progresses. Particular attention is paid to the control blood pressure, the condition of the fundus, the dynamics of the relative density of urine according to Zimnitsky, the value of glomerular filtration, the concentration of nitrogenous wastes and the content of electrolytes in the blood. These studies are carried out depending on the severity of chronic renal failure monthly or every 2-3 months.

Chronic pyelonephritis is a disease characterized by the development of inflammatory processes in the kidney tissues. As a result, a person undergoes destruction of the pelvis, as well as the vessels of the organ. To protect yourself from this unpleasant pathology, you should carefully study the main causes, symptoms, as well as modern methods of diagnosis and treatment.

The definition of chronic pyelonephritis applies to a disease that long time proceeds latently and can be activated only under certain conditions. If the disease was diagnosed in childhood or adolescence, then there is a high probability of its return in a more mature period.

Among the main factors that contribute to the development of the disease, there are:

• hypervitaminosis and hypovitaminosis;
• severe hypothermia, as well as a long stay in a stuffy room;
• decrease in the level of human immunity;
• frequent overwork, stress;
• negative impact of infectious factors;
• the presence of diseases of other organs of the abdominal cavity and small pelvis.

Most common cause development of chronic pyelonephritis in men is androgen deficiency. It is caused by a change in the hormonal balance, and the presence of tumor-like neoplasms of the prostate is also possible.

There are many more factors that contribute to the development of such a disease as bilateral chronic pyelonephritis in women.

They should include:

• small length of the urinary canal;
• the presence of the microflora of the large intestine in the outer part of the vagina;
• residual effects of urine in the bladder;
• frequent lesions of infectious agents of the bladder during close sexual contact.

Often, the pathology is activated during pregnancy. At this time, the protective function of the immune system is significantly reduced. This is due to the limitation of rejection of the fetus in the woman's body.

Pathology has several types. The classification of chronic pyelonephritis implies its division into primary and secondary forms. The first acts as an independent disease, and the second develops against the background of previous lesions of the genitourinary system. According to localization in chronic pyelonephritis, classification into unilateral and bilateral pathology. In this case, we are talking about the defeat of the disease of one or two kidneys.

Poorly expressed symptoms, a frivolous attitude to therapy, as well as an incomplete awareness of the danger of chronic pyelonephritis are the main prerequisites for the transition of this disease to a chronic form. For this reason, it is very important to know the symptoms and treatment of pathology.

All symptoms of chronic pyelonephritis can be divided into local and general. The first signs are more pronounced in women. They appear in people who have a secondary form of chronic pyelonephritis. This is due to the presence of factors that disrupt the normal outflow of urine. In men, the symptoms are less pronounced, which significantly complicates the diagnosis of pathology.

General signs of chronic pyelonephritis have their own classification. They are made for early manifestations and late ones.

The first experts include:

• cachexia;
• episodic asthenia;
• obstruction of the urinary tract;
• absolute or relative lack of appetite;
• small rises in blood pressure;
• poor tolerance of habitual physical work;
• pain syndrome.

Exacerbation of these processes can lead to the development of acute renal failure. The progression of the disease itself usually leads to chronic renal failure. This condition is characterized by the presence of irreversible disorders in the urinary system.

This pathology manifests itself with:

• unpleasant pain in the lumbar region;
• dry mouth, as well as some gastralgic symptoms;
• suppressed psychological activity;
• pallor of the skin;
• polyuria.

Late symptoms of chronic pyelonephritis often indicate that both organs are affected in the patient, and there is also a possibility of chronic renal failure. In making a residual diagnosis, an important role is played by clinical manifestations, as well as diagnostic data and stages of pathology.

Experts distinguish 3 stages of chronic pyelonephritis:

1. The initial stage of the pathology is characterized by the development of inflammatory processes, especially swelling of the connective ball of the inner layer of the urinary system, which cause compression of the vascular structures. As a result, tubular atrophy develops.
2. The next stage is accompanied by the presence of a diffuse narrowing of the arterial bed of the kidneys, as well as atrophy of the walls of the interlobar vessels.
3. The third stage is due to compression and obturation of all vascular structures of the kidneys. In this case, the tissue of this organ is replaced by connective tissue. This gives the organ the appearance of prunes and kidney failure develops.

The diagnosis of chronic pyelonephritis is made on the basis of a comprehensive examination of the patient. Setting an accurate result requires various instrumental and laboratory methods research.

The first experts include:

1. Performing radiography. chronic course pathology is characterized by a decrease in the size of the kidneys.
2. Chromocystoscopy. In chronic pyelonephritis in the kidneys, the doctor may notice a violation of the excretory function of the genitourinary system.
3. Radioisotope scanning method, which reveals the asymmetry of the kidneys, as well as their deformation or heterogeneity.
4. Excretory and retrograde pyelography, which allows you to notice any pathological processes in the organ.
5. Ultrasound procedure.
6. Computed tomography and magnetic resonance imaging.
7. Biopsy of the organs of the urinary system, as well as the diagnosis of the material obtained.

The formulation of the diagnosis occurs after a comprehensive diagnosis of pathology.

This will help the implementation of special laboratory research methods:

1. General blood analysis. Chronic pathology can be indicated by anemia, a high level of leukocytes, as well as an increased erythrocyte sedimentation rate.
2. General urine analysis. In this case, the material of the patient will have an alkaline environment. Urine will have a low density and a cloudy color. May have cylinders. The number of leukocytes is increased.
3. Nechiporenko test. It can be used to discover increased rates leukocytes, as well as their active component.
4. Prednisolone, as well as pyrogenal test. In this case, the patient is given a special dose of the drug and after a while a certain amount of urine is collected.
5. Zimnitsky test. In this case, several portions of urine are collected during the day with the determination of its density.
6. LHC analysis will help to identify the level of sialic acids, urea and fibrin.

When asked whether chronic pyelonephritis can be cured, many experts give a negative answer. The treatment strategy is individual approach to each patient, as well as in the complex use of different methods of therapy, which are aimed at his speedy recovery. It consists in observing the diet, following the doctor's instructions regarding the reception medicines, as well as the elimination of factors that prevent the normal outflow of urine.

In the presence of chronic pyelonephritis symptoms, the patient should be treated in a hospital. This will help in a short time to stop attacks, as well as effectively cope with their causes. With the primary form of the disease, patients are determined in the therapeutic department, and in the secondary form - in the urological department.

The duration of bed rest depends entirely on the course of pyelonephritis. In this case, it is imperative to follow a special diet, which is an important point in the treatment of this pathology.

Treatment of chronic pyelonephritis in women has several nuances. In this case, one of the main tasks is to reduce the amount of edema, which is often observed in this disease. Compliance with the drinking regime is accompanied by the use of such drinks as water, fruit drinks, juices, as well as homemade compotes and jelly. The volume of liquid should not exceed two liters per knock. Only a doctor can change the amount of its consumption. This he can do on the basis of the patient's primary arterial hypertension or changes in the passage of urine.

This disease in the treatment involves the use of antibiotics. They can be prescribed in the early stages of the development of chronic pyelonephritis. The period of their use is long, since bacterial agents tend to develop resistance to certain drugs. Only a doctor knows how to treat pathology with the help of these means, so you should not self-medicate in order to avoid the development of serious complications.

Therapy for chronic pyelonephritis is to use the following groups of drugs:

1. Semi-synthetic penicillins. These include Ampicillin, Sultamicillin, Oxacillin and Amoxiclav.
2. Cephalosporins. Among them are Ceftriaxone, Cefixime, Kefzol and Tseporin.
3. Nalixidic acid preparations. Among them, Nevigramon and Negram are the most effective.
4. Aminoglycosides. These include Amikacin, Gentamicin and Kanamycin.
5. Fluoroquinolones, namely Ofloxacin, Moxifloxacin and Levofloxacin.
6. Antioxidants. In this case, the treatment is reduced to the use of Retinol, Ascorbic acid and Tocopherol.

In chronic pyelonephritis of the kidneys, you must first study the acidity of the patient's urine. This factor has an adverse effect on the effectiveness of drug therapy.

Chronic obstructive pyelonephritis can be called successfully cured if several criteria are met.

Among them it is worth highlighting:

1. Normalization of indicators of urine and blood.
2. Stabilization of the patient's temperature.
3. Absence of leukocyturia, proteinuria and bacteriuria.

A positive result of treatment does not protect against the possibility of recurrence of the pathology. The probability of this phenomenon is 70-80%. For this reason, doctors recommend therapy that eliminates risk factors for the recurrence of the disease for many months after successful treatment of the pathology.

If during the treatment of acute chronic pyelonephritis an allergy to medications occurs, the patient is prescribed antihistamines.

These include:

• Tavegil;
• Diazolin;
• Corticosterone.

In primary chronic pyelonephritis, anemia often develops. To eliminate it, iron preparations, vitamin B12, and folic acid are used.

Bilateral pyelonephritis in men in most cases is accompanied by secondary arterial hypertension. In this case, antihypertensive drugs are used, among which Hypothiazid, Triampur and Reserpine are considered the most effective.

In the presence of chronic pyelonephritis in the kidneys, treatment should be started as early as possible. This will reduce the number and nature of destructive changes, which will favorably affect the patient's health.

The result of the outcome of chronic pyelonephritis directly depends on the observance of a special diet. It consists in limiting spicy, fried, smoked foods, as well as various seasonings from the patient's diet.

It is not recommended to underestimate the daily need for calories. The diet should be balanced in terms of the amount of proteins, fats and carbohydrates. Equally important is the presence of a large amount of vitamins and minerals in food.

An optimal diet should contain a wide variety of vegetables: cabbage, beets, potatoes, and greens. Fruits rich in vitamins and fiber are also recommended.

Iron deficiency in chronic pyelonephritis is treated with strawberries, pomegranates, apples. At any stage of the disease, watermelons, melons, cucumbers, pumpkins will be useful. These products have a diuretic effect, which allows you to quickly cope with the pathology.

Meat and fish should be served exclusively boiled and without salt. It retains water in the body of the patient. It is advisable to exclude pork because of its high fat content in the presence of pyelonephritis in men.

Preventive measures applied to such a disease as chronic pyelonephritis are aimed at reducing the overall incidence of the population.

Among them it is worth highlighting:

1. Timely treatment of patients, as well as dispensary registration of patients with an acute form of pathology.
2. Special recommendations for the employment of people with this disease. Such patients are not recommended to perform hard physical labor and stay in constant nervous tension. It is also worth choosing a job where there are no temperature changes and being in a static position for a long time.
3. Compliance proper nutrition with a limited amount of salt, fried, fatty and spicy foods.
4. Complete elimination of the cause of the development of a secondary form of pathology. Also an important point is the complete elimination of obstacles to the normal outflow of urine.
5. Rapid identification of foci of infection.
6. Dispensary observation of patients who have recovered during the year. If during this period the patient does not have leukocyturia, proteinuria and bacteriuria, then the patient is removed from the register. If these signs persist, the observation is extended for up to three years.
7. The placement of patients with the primary form of the disease in a hospital, where they are treated under the supervision of medical personnel.
8. Correction immune system. For this, you should follow healthy lifestyle life, proper nutrition, spending free time in the fresh air, as well as dosed physical activity.
9. Visiting sanatorium-resort establishments with a specialized profile. In this case, remission of the pathology is often achieved.
10. Preventive actions are aimed at people with a weakened immune system. These include pregnant women, children and the elderly.

With a latent course of the disease, patients do not lose their ability to work for a long time. Other forms of the disease have a significant impact on the patient's performance, since there is a possibility of rapid development of severe complications.

It is worth remembering that early diagnosis of the disease significantly increases the chances of favorable treatment and reduces the likelihood of relapses. Therefore, when the first symptoms appear, you should immediately consult specialized specialists, because only they know how to cure pyelonephritis forever, and they can save the main value of a person - his health!

Antibiotics for pyelonephritis: which drug to choose

Referring to the statistics, we can say that at present the disease pyelonephritis is widespread - inflammation of the kidneys, the causative agents of which are bacteria.

This disease affects, most often, children of the school age group, aged 7-8 years. This is due to the peculiar anatomical structure of their urinary system, as well as the need to adapt to school.

Predisposed to it and girls, women of the age of active sexual life. Men of the older age group also suffer from the disease, especially with prostate adenoma.

The clinical picture unfolds with a headache, aching muscles, a rise in body temperature to 38-39 degrees for a short period of time, accompanied by chills.

If you have these symptoms, you should urgently contact the nearest clinic for examination, where the doctor will select and prescribe the appropriate treatment program, or call a specialist at home, so as not to cause complications of pyelonephritis.

Treatment of pyelonephritis of the kidneys is carried out in a hospital, in which bed rest, heavy drinking, diet are recommended, and antibiotics (antibacterial drugs) are required. How to treat pyelonephritis with antibiotics?

Why are antibiotics effective in the fight against pyelonephritis?

Antibiotics are drugs (of natural or semi-synthetic origin) that can blunt or interfere with the growth or death of certain microorganisms. With pyelonephritis, antibiotics are most often prescribed in tablets. Moreover, the main requirements for antibacterial drugs in the treatment of pyelonephritis should be the presence of:

• their high concentration in the urine,
• they should not have a toxic effect on the patient's kidneys.

What antibiotic is better to take for pyelonephritis? To answer this question, it is necessary to conduct a survey in which

• identify the causative agent of pyelonephritis,
• determine the condition and function of the kidneys,
• determine the state of the outflow of urine.

In the event of the occurrence and development of pyelonephritis, the main role is assigned to bacteria (microorganisms) that mainly affect the tissues of the kidney, its pelvis and calyx, therefore, in the forefront, in the complex treatment of the disease, it is worth using

• antibiotics (Ampicillin, Amoxicillin, Cefaclor, Gentamicin).
• sulfonamides (Co-Trimoxazole, Urosulfan, Etazol, Sulfadimezin).

Although they are prescribed for mild forms of the disease, sulfonamides are rarely used at present.

In the absence of one of the two conditions, the use of drugs is not used.

• nitrofurans (Furadonin, Furagin, Furazolin)

Antibacterial drugs with a wide spectrum of action, and their concentration in the patient's urine is observed (reasons clinical researches drugs) within 10-15 hours.

• production of nalidixic acid (Negram, Nalidix).

Well tolerated by the body, but have little effect.

Advantages of antibiotics over herbal remedies and other medicines

• treatment with phytopreparations and the achievement of the result occurs for a long period of time (during which pain and spasms torment). The course of antibiotics, as a rule, does not exceed a week and gives a quick effect.
• excessive use of herbal remedies can cause a diuretic effect, the consequence of which will be the “movement” of stones (the result of a secondary form of pyelonephritis).
• the action of antibiotics is directed at the focus of the disease itself and does not affect other areas (elimination of bacteria, normalization of body temperature, elimination of sediment in the composition of urine).

Antibacterial agents for the treatment of pyelonephritis

In mild forms of pyelonephritis, treatment is carried out with drugs:

• Urosulfan,
• Etazol,
• Sulfadimezin

They stop the growth of bacterial cells, are well absorbed from the stomach, and are not deposited in the urinary tract.

If there is no improvement within 2-3 days from the start of taking the drugs listed above, experts recommend adding the following antibiotics (taking into account microbial infection). These include:

• Penicillin

• Erythromycin

It is not prescribed for lactating women, it is possible to influence the baby through breast milk. Use by children is possible.

• Oleandomycin

It is an outdated tool. AT modern medicine practically not used and replaced by newer drugs.

• Levomycetin

During pregnancy is contraindicated. Designed for children from 3 years.

• Colimycin
• Mycerin.

In purulent forms of pyelonephritis, drugs are prescribed intravenously (antibiotics)

• Gentamicin
• Sizomycin.

All drugs are aimed at blocking the development and inhibition of microorganisms that affect the development of pyelonephritis.

The most commonly used in practice are:

• Aminopenicillins (Amoxicillin, Ampicillin). Block the development of enterococci, Escherichia coli. They are prescribed for pregnant women in the treatment of inflammatory processes in the kidneys.
• Flemoklav Solutab (polysynthetic antibiotic). The difference and usefulness of this drug, from others, is in prescribing it to children from 3 months and pregnant women (most drugs are contraindicated).
• Cephalosporin antibiotics (semi-synthetic and natural preparation). It is prescribed when there is a predisposition to the transition of pyelonephritis from an acute form to a purulent one. In most patients, there is an improvement in the condition on the 2nd day of taking the drug. This type includes:

1. Cefalexin
2. Cefalotin
3. Zinnat
4. Claforan
5. Tamycin.

• Aminoglycosides (Gentamicin, Amikacin, Tobramycin). They are prescribed for severe pyelonephritis. They have a nephrotoxic effect, can affect hearing loss. They are not assigned to people of the older age category and their repeated use is allowed after a year from the start of the first application.
• Fluoroquinolones. These include:

1. Ciprofloxacin.

They have a wide spectrum of activity and are well tolerated by patients. Have minimal toxic effect on the body. Treatment with these antibiotics is prescribed for chronic pyelonephritis. Not prescribed for pregnant women.

Thus, for the treatment of pyelonephritis, today, there is a huge number of different drugs intended for both initial and subsequent forms of the disease.

The expediency and rationality of use depends on complex treatment chosen by the specialist.

It should be noted that dose selection depends on individual features patient (kidney anatomy, urine composition).

At the same time, of course, it is much easier to deal with the disease in the early stages. That is why you should not start a painful condition and self-medicate. At the first symptoms of the disease - immediately consult a doctor.

Symptoms and treatment of kidney pyelonephritis

Pyelonephritis of the kidneys is a bacterial lesion of its internal structure, mainly the pelvicalyceal system.

With untimely or ineffective therapy, the disease may become chronic, the formation of a purulent abscess and a violation of the basic functions of the kidney up to its complete atrophy.

Mostly pyelonephritis affects women of childbearing age. Very often it develops simultaneously with the onset of sexual activity, during pregnancy or after childbirth.

In men, this disease most often occurs in adulthood. In most cases, this is due to impaired urodynamics in prostatic hyperplasia and muscular dysfunction of the urinary tract.

Among the diseases of children under the age of three years, pyelonephritis is in second place after diseases of the upper respiratory tract.

Etiology of the disease

The main causative agents of pyelonephritis are Escherichia coli and Staphylococcus aureus. In addition, the causes of this disease can be Klebsiella, Proteus, fungi of the Candida species.

Infection can enter the kidney in several ways:

• ascending with the reverse reflux of urine into the pyelocaliceal system;
• hematogenous with blood flow from the foci of infection of any localization;
• lymphogenous with lymph flow.

Accordingly, this disease is caused by such reasons:

• diseases that lead to a violation of the outflow of urine from the kidneys, such as prostate adenoma in men, tumor diseases of nearby organs, scars on the ureters after surgical interventions;
• chronic cystitis;
• sluggishly current inflammatory processes caused by staphylococcus, proteus or klebsiella;
• genital infections;
• vesicoureteral reflux in children;
• stasis of urine in neurogenic dysfunctions of the bladder.

According to the results of studies, one infection of the lower urinary system or genital organs is not enough for the development of pyelonephritis.

The main role is played by a violation of the passage of urine, as well as a significant weakening of the immune system in humans against the background of constant stress, overwork, beriberi. An exception is pyelonephritis in children.

Due to the features anatomical structure in early age the infection easily "rises" up the urinary tract to the kidneys. This disease is especially common in girls.

This is mainly due to insufficient hygiene of the perineum. In boys, phimosis (narrowing of the foreskin) is a common cause of pyelonephritis.

Separately, it is worth mentioning the role of hormones in the development of pyelonephritis.

In the course of medical experiments, it was found that long-term use hormonal drugs for treatment or contraception, as well as hormonal imbalance in women as a result of illness or pregnancy leads to changes in the structure of the renal tissue.

It is also a factor contributing to the occurrence of pyelonephritis against the background of another infection, such as cystitis.

This disease also occurs in almost half of people with diabetes. This is caused by a whole complex of general disorders in the body.

With regard to chronic pyelonephritis, the development of bacterial resistance to antibiotics plays a significant role.

Most often this is due to excessive self-medication, taking antibacterial drugs for no good reason, an unfinished course of treatment with antimicrobial agents.

What happens during bacterial inflammation?

The mechanism of development of inflammation depends on how the infection got into the kidney. If the causative agents of pyelonephritis were brought in by the blood or lymph flow, then, first of all, the renal tissue and the nephrons located in it are affected.

After all, it is there that the main capillary and lymphatic network of vessels passes.

If the bacteria are brought into the kidney by an ascending route through the ureter, then the primary inflammation covers the pelvicalyceal system, and the renal tissue is affected with a long course of the disease or no treatment.

If the patient does not receive adequate therapy, then over time, the process of formation of purulent abscesses begins in the kidney, which covers all its internal sections.

This condition can even lead to permanent dysfunction of the organs and even to their atrophy.

Classification

Currently, there is no exact and generally accepted classification of pyelonephritis. This disease is caused by a sufficiently large number of reasons, characterized by a variety of changes in the renal structure.

But most often in medical practice, various forms of pyelonephritis are classified as follows:

• according to the nature of the course into acute and chronic, which in most cases develops against the background of ineffective treatment of acute pyelonephritis;
• by localization - on unilateral and bilateral, although often this disease affects only one kidney;
• depending on the general condition of the patient - complicated by concomitant pathologies and uncomplicated;
• due to development - to the primary, which develops against the background of a normal passage of urine, and the secondary, which occurs when there is a violation of urodynamics.

The clinical symptoms of pyelonephritis depend on the form in which it proceeds - acute or chronic.

So for acute pyelonephritis is characterized by a sharp increase in temperature to 38.5 - 39º. At the same time, there is clouding of urine, a change in its smell. The patient complains of aching pain in the lower back.

At the same time, if the edge of the palm is tapped on the back under the shoulder blade, then the pain syndrome will intensify from the side of the affected kidney.

The difference from the pain syndrome in urolithiasis is that the intensity of pain does not change depending on the movement or change in posture.

These symptoms are accompanied by increased fatigue, drowsiness, sometimes nausea or vomiting, loss of appetite.

Almost from the very beginning of the disease, urination disorders are noted, the urge to urinate becomes more frequent, the process itself is accompanied by pain.

If the formation of purulent abscesses has begun, then a wave-like increase in temperature is characteristic: usually, after its sharp increase to 38-39º, it decreases to subfebrile values.

It should be noted that in children the symptoms of pyelonephritis may differ, in addition, it is clear that a small child cannot say that he is in pain.

Therefore, most often the only symptoms of a bacterial kidney infection are fever and lethargy.

As for the chronic form of pyelonephritis, the symptoms may not appear at all for a long time. Unless there is a prolonged subfebrile temperature after suffering colds.

The disease in this form proceeds with alternating periods of exacerbation and remission.

In the exacerbation phase, symptoms characteristic of acute pyelonephritis are noted: fever in the evenings, general deterioration of the condition, which is associated with prolonged intoxication, lower back pain, cramps during urination, frequent urge to urinate.

The color and transparency of urine also changes. In the remission phase, there may be no symptoms, and the disease is detected only during clinical examination.

At the late stage of chronic pyelonephritis, symptoms of renal failure are noted: swelling in the face, increased blood pressure, changes in the rhythm of the heartbeat.

Diagnostics

Naturally, if such symptoms are observed, then this is a reason for an urgent visit to the doctor. Before treating any nephrological pathology, it is necessary to determine the exact localization of the infection.

This disease is diagnosed by characteristic changes in blood and urine tests, as well as on x-rays or ultrasound of the kidneys.

AT clinical analysis urine there is a significant increase in the number of leukocytes, usually they occupy the entire field of view. Severe bacteriuria is also found.

When involved in the inflammatory process of the renal tissue or the epithelial wall of the pyelocaliceal system, erythrocytes may also appear in the urine. In addition, the value of the protein level is also above the norm.

In the blood, there is an increase in the level of leukocytes and ESR, and these are direct symptoms of the development of a bacterial infection.

In violation of the excretory function of the kidneys (this is typical for bilateral pyelonephritis), the concentration of creatinine, urea and other metabolic products increases.

An ultrasound or radiograph shows an expansion of the pyelocaliceal system, a change in the structure of the renal tissue.

With pyelonephritis, a urine culture is required to determine sensitivity to antibiotics. But it takes about 3-5 days to complete this analysis, therefore, in the acute course of this disease, treatment is started immediately.

And upon receipt of the results of the study, the treatment regimen is adjusted.

Treatment

Treatment of pyelonephritis is only medical. For constant monitoring of the patient's condition and kidney function, it must be carried out in a hospital setting.

It is especially important to treat children only in the hospital, since so many medicines for the treatment of this disease are injected and can cause a severe allergic reaction.

The main treatment of pyelonephritis is carried out with antibacterial agents that affect the pathogenic microflora.

Usually prescribed combinations of two to three drugs. In severe cases, these drugs are administered intramuscularly, but if the patient's condition allows, then, in principle, one can limit oneself to tablets or suspensions.

As mentioned above, pyelonephritis should be treated with regular bakposev. Depending on the results of the analysis, the treatment is corrected: they can change the drugs themselves or extend the course of administration.

Selection of antibiotics is based on their toxic effects on the kidneys. Naturally, treatment is carried out with drugs with minimal nephrotoxicity.

Treatment with non-steroidal anti-inflammatory drugs helps to reduce the intensity of the inflammatory process. They also prescribe drugs that improve blood flow in the kidneys.

Treatment with the help of the so-called functional passive kidney gymnastics is very effective. This method consists in the periodic intake of diuretic drugs.

Such therapy is carried out only under the strict supervision of a physician, since an overdose of diuretics may wash out trace elements in the microorganism. This can lead to a significant deterioration in the patient's condition.

To improve the functioning of the immune system, treatment with immunomodulators and immunostimulants is carried out.

Diet

It takes much longer to treat pyelonephritis if the patient does not adhere to a certain diet.

So, in acute pyelonephritis, natural juices, weak tea, compotes, cranberry juice, rosehip broth supplement the treatment.

Depending on the time of year, pumpkin, watermelons, zucchini or other vegetables and fruits that have a diuretic effect must be present in the diet.

Salt intake should be reduced, especially if the disease is accompanied by an increase in blood pressure.

In chronic pyelonephritis, the diet is approximately the same as in acute. The diet must be designed in such a way as to prevent the development of beriberi.

The menu must contain lean meat and fish, lean dairy products, vegetables and fruits. It is worth using honey instead of sugar.

Fractional meals (5-6 meals a day) are considered ideal.

Timely treatment of pyelonephritis guarantees a favorable outcome of the disease with complete restoration of kidney function. A wide range of modern drugs allows you to treat this disease in infants and pregnant women.

Clinical guidelines include advice on diagnosis and therapeutic measures for inflammation of the kidneys. Focusing on the recommendations, the doctor examines, diagnoses and treats the patient in accordance with the form of the disease and its causes.

Description and forms

Pyelonephritis is an inflammatory disease that affects the renal tissue and the pelvicalyceal system (PCS). The cause of the disease is the development of an infection that sequentially affects the parenchyma, then the calyx and pelvis of the organ. Infection can also develop simultaneously in the parenchyma and PCS.

In the vast majority of cases, the causative agents are Escherichia coli, streptococcus, staphylococcus, less often Klebsiella, Enterobacter, Enterococcus and others.

Depending on the effect on the process of urination, inflammation can be primary and secondary. In the primary form, urodynamic disturbances are not observed. In the secondary form, the process of formation and excretion of urine is disrupted. The causes of the latter type can be pathologies of the formation of the organs of the urinary system, urolithiasis, inflammatory diseases of the genitourinary organs, benign and malignant tumor formations.

Depending on the localization of the inflammatory process in the kidneys, the disease can be unilateral (left-sided or right-sided) and bilateral.

Depending on the form of manifestation, pyelonephritis occurs acutely and chronically. The first develops rapidly as a result of the multiplication of bacterial flora in the organ. The chronic form is manifested by a long course of symptoms of acute pyelonephritis or its multiple relapses during the year.

Diagnostics

Pyelonephritis is accompanied by a feeling of pain in the lower back, fever and changes in the physicochemical properties of urine. In some cases, with inflammation of the kidneys, there may be feelings of fatigue and weakness, headaches, upset of the digestive tract, and thirst. Pyelonephritis in children is accompanied by increased excitability, tearfulness and irritability.

In the course of diagnostic measures, the doctor must determine what led to the development of the inflammatory process in the kidneys. For this purpose, a survey is conducted, during which the presence of chronic diseases, inflammatory diseases of the urinary system in the past, anomalies in the structure of the organs of the urinary system and disorders in work are determined. endocrine system, immunodeficiency.

During the examination with pyelonephritis, the patient can be identified fever body accompanied by chills. During palpation, pain occurs in the kidney area.

To identify the inflammatory process in the kidney, tests are performed to detect leukocyturia and bacteremia. An increase in leukocytes in the urine is determined using test strips, a general analysis and an analysis according to Nechiporenko. The most accurate are the results of laboratory studies (sensitivity of about 91%). Test strips have a lower sensitivity - no more than 85%.

The presence of bacterial flora will show a bacteriological analysis of urine. During the study, the number of bacteria in urine is counted, by the number of which the form of the course of the disease is established. Bacteriological analysis also makes it possible to determine the type of bacteria. It is important in the course of studying the microflora of urine to find out the resistance of the pathogen to antibiotics.

General clinical, biochemical and bacteriological blood tests help to determine the clinic of the disease. In primary pyelonephritis, a blood test is rarely used, since the results of the analysis will not show significant deviations. With secondary pyelonephritis, there is a change in the indicators of leukocytes, as well as the erythrocyte sedimentation rate. Biochemical research blood is carried out according to indications, in the presence of other chronic diseases or if complications are suspected. A bacteriological blood test helps to confirm the type of infectious agent.

Instrumental diagnostic methods will help clarify the diagnosis, determine the condition of the kidneys and organs of the urinary system, and establish the cause of the development of inflammation. With the help of ultrasound, you can see the presence of stones, tumors, purulent foci in the organs. The development of pyelonephritis will be indicated by the increased size of the pyelocaliceal system.

If symptoms worsen within 3 days after the start of treatment, computed tomography, X-ray diagnostics with the introduction of a contrast agent are prescribed. If you suspect malignant neoplasms that were detected during ultrasound, cystoscopy is required.

Treatment should be aimed at eliminating the focus of the disease, preventing complications and relapses.

In primary pyelonephritis of the acute form, treatment is carried out on an outpatient basis with the help of antibacterial agents. Treatment in a hospital is carried out according to indications or in the absence of the effect of the drugs used.

Hospitalization is necessary for patients with secondary inflammation that can lead to serious complications as a result of poisoning the body with toxic compounds.

Urgent hospitalization is also required for patients with one kidney, an exacerbation of a chronic inflammatory process that occurs with symptoms of renal failure. In a hospital, treatment is necessary in the presence of other chronic diseases (diabetes mellitus, immunodeficiency) and with the accumulation of pus in the kidney cavity.

Treatment

Non-drug treatment involves drinking the right amount of fluid to help maintain adequate urination. For this purpose, diuretics are used. The diet excludes the use of fried, fatty, spicy foods, baked goods and salt.

Medical treatment implies a course of antibacterial drugs that are prescribed taking into account their compatibility, the patient's allergies, concomitant diseases, the patient's special condition (pregnancy or lactation).

The appointment of antibiotics is carried out immediately after the detection of pyelonephritis. General antibiotics are used. After the results of bacteriological analysis, specific antibiotics are prescribed.

After 48-72 hours, the effectiveness of therapy is monitored. After the results of the analysis, in the absence of effectiveness, a decision is made regarding the appointment of other drugs or an increase in the dose of the prescribed ones.

For the treatment of the primary form, fluoroquinolones, cephalosporins, and protected aminopenicillins are prescribed. In a secondary inflammatory process, aminoglycosides are added to the specified list of drugs.

During pregnancy, pyelonephritis is treated outside the hospital with antibiotics in the absence of a threat of abortion. In other cases, hospitalization is required. Protected aminopenicillins, cephalosporins, aminoglycosides are used for treatment. Fluoroquinols, tetracyclines, sulfonamides are strictly contraindicated.

In complicated pyelonephritis, ureteral catheterization or percutaneous nephrostomy (PNS) is preferred. These methods involve the installation of a drainage system and are aimed at normalizing the passage of urine.

Operations in an open way are carried out with the formation of pus, the prolongation of the disease, the inability to use minimally invasive methods of surgical intervention.

Timely diagnosis and properly prescribed therapy give a great chance for a favorable outcome of the course of pyelonephritis. Antibiotics, diet, water regimen are used for treatment. According to indications, surgical intervention is prescribed.

Chronic pyelonephritis is a sluggish, periodically aggravated bacterial inflammation of the interstitium of the kidney, leading to irreversible changes in the pelvicalyceal system, followed by sclerosis of the parenchyma and wrinkling of the kidney. By localization, chronic pyelonephritis can be unilateral or bilateral, affecting one or both kidneys. Bilateral chronic pyelonephritis usually occurs.

Often chronic pyelonephritis (CP) is the result of improper treatment of acute pyelonephritis (AP).

In a significant proportion of patients who have had acute pyelonephritis or exacerbation of chronic pyelonephritis, a relapse of chronic pyelonephritis occurs within 3 months after the exacerbation.

The prevalence of chronic pyelonephritis in Russia is 18-20 cases per 1000 people, while in other countries acute pyelonephritis is completely cured without becoming chronic.

Although the complete curability of acute pyelonephritis in 99% of cases has been proven worldwide, and the diagnosis of "chronic pyelonephritis" is simply absent in foreign classifications, mortality from pyelonephritis in Russia, according to the causes of death, ranges from 8 to 20% in different regions.

The low effectiveness of the treatment of acute and chronic pyelonephritis is associated with the lack of timely conduct by general practitioners of express tests using test strips, the appointment of long-term unreasonable examinations, incorrect empiric prescription of antibiotics, visits to non-core specialists, self-treatment attempts and late seeking medical help.

Types of chronic pyelonephritis

Chronic pyelonephritis - ICD-10 code

• №11.0 Non-obstructive chronic pyelonephritis associated with reflux
• №11.1 Chronic obstructive pyelonephritis
• №20.9 Calculous pyelonephritis

According to the conditions of occurrence, chronic pyelonephritis is divided into:

• primary chronic pyelonephritis developing in an intact kidney (without developmental anomalies and diagnosed disorders of urinary tract urodynamics);
• secondary chronic pyelonephritis, which occurs on the background of diseases that violate the passage of urine.

Chronic pyelonephritis in women

Women suffer from pyelonephritis 2-5 times more often than men, which is associated with the anatomical features of the body. In women, the urethra is much shorter than in men, so bacteria can easily penetrate through it from the outside into the bladder and from there through the ureters can enter the kidneys.

The development of chronic pyelonephritis in women is facilitated by factors such as:

• pregnancy;
• gynecological diseases that violate the outflow of urine;
• the presence of vaginal infections;
• use of vaginal contraceptives;
• unprotected intercourse;
• hormonal changes in the premenopausal and postmenopausal periods;
• neurogenic bladder.

Chronic pyelonephritis in men

In men, chronic pyelonephritis is often associated with difficult working conditions, hypothermia, poor personal hygiene, and various diseases that interfere with urine outflow (prostate adenoma, urolithiasis, sexually transmitted diseases).

The causes of chronic pyelonephritis in men can be:

• prostatitis;
• stones in the kidneys, ureters, bladder;
• unprotected sex;
• STDs (sexually transmitted diseases);
• diabetes.

Causes of chronic pyelonephritis

In the formation of primary chronic pyelonephritis, an important role is played by the infectious agent, its virulence, as well as the nature of the body's immune response to the pathogen. The introduction of an infectious agent is possible by ascending, hematogenous or lymphogenous routes.

Most often, the infection enters the kidneys by ascending through the urethra. Normally, the presence of microflora is permissible only in the distal urethra, however, in some diseases, the normal passage of urine is disturbed and urine is thrown back from the urethra and bladder into the ureters, and from there to the kidneys.

Diseases that violate the passage of urine and cause chronic pyelonephritis:

• anomalies in the development of the kidneys and urinary tract;
• urolithiasis disease;
• strictures of the ureter of various etiologies;
• Ormond's disease (retroperitoneal sclerosis);
• vesicoureteral reflux and reflux nephropathy;
• adenoma and sclerosis of the prostate;
• sclerosis of the neck of the bladder;
• neurogenic bladder (especially hypotonic type);
• cysts and tumors of the kidney;
• neoplasms of the urinary tract;
• malignant tumors of the genital organs.

Risk factors (FR) for urinary tract infections are presented in Table 1.

Table 1. Risk factors for urinary tract infections

Causative agents of chronic pyelonephritis

The most common pathogens of pyelonephritis are microorganisms of the Enterobacteriaceae family (with Escherichia-coli accounting for up to 80%), less often Proteus spp., Klebsiella spp., Enterobacter spp., Pseudomonas spp, Staphylococcus Saprophyticus, Staphylococcus Epidermidis, Enterococcus Faecalis, and also fungal microflora, viruses, L-forms of bacteria, microbial associations (E. coli and E. faecalis are more often combined).

However, a simple infection of the urinary tract for the formation of chronic primary pyelonephritis is not enough. For the implementation of the inflammatory process, a simultaneous combination of a number of conditions is necessary: ​​the manifestation of the virulent properties of an infectious agent, the inadequacy of the body's immune response to a given pathogen, impaired urodynamics and/or renal hemodynamics, usually initiated by the infection itself.

Currently, the role of immune system disorders in the pathogenesis of chronic primary pyelonephritis is beyond doubt. In patients with this type of pathology in the phase of active inflammation, there is a decrease in all indicators of phagocytosis, incl. oxygen-dependent effector mechanisms as a result of depletion of bactericidal systems of phagocytic cells.

Chronic pyelonephritis, the most common kidney disease, manifests itself as a non-specific infectious and inflammatory process that occurs mainly in the tubulointerstitial zone of the kidney.

There are the following stages of chronic pyelonephritis:

• active inflammation;
• latent inflammation;
• remission or clinical recovery.

Exacerbation of chronic pyelonephritis

In the active phase of chronic pyelonephritis, the patient complains of dull pain in the lumbar region. Dysuria (urination disorders) is uncharacteristic, although it may be present in the form of frequent painful urination of varying severity. With a detailed questioning, the patient can bring a lot of non-specific complaints:

• episodes of chilling and subfebrile condition;
• discomfort in the lumbar region;
• fatigue;
• general weakness;
• decrease in working capacity, etc.

Latent pyelonephritis

In the latent phase of the disease, there may be no complaints at all, the diagnosis is confirmed by laboratory tests.

The stage of remission is based on anamnestic data (for at least 5 years), complaints and laboratory changes are not detected.

With the development of chronic renal failure (CRF) or tubular dysfunction, complaints are often determined by these symptoms.

Tests for chronic pyelonephritis

As a screening method of examination for chronic pyelonephritis, a general urinalysis and ultrasound of the kidneys are used, supplemented by asking the patient about the characteristic manifestations of chronic pyelonephritis and diseases that contribute to its development.

What tests should be done in chronic pyelonephritis:

• Urinalysis (OAM)
• Complete blood count (CBC)
• Urine bacterioscopy
• blood glucose
• Creatinine and blood urea
• Ultrasound of the kidneys
• Pregnancy test
• Survey urography
• Bacteriological examination of urine

Urine and blood tests for chronic pyelonephritis

In a laboratory study of urine, leukocyturia (in most cases neutrophilic) and bacteriuria are detected. Small proteinuria (protein in the urine up to 1 g / day), microhematuria (hidden blood in the urine), hypostenuria (urine with a constantly low relative density), alkaline urine reaction (pH> 7) are possible.

Bacteriological analysis of urine is indicated for all patients to identify the causative agent of the disease and prescribe adequate antibiotic therapy. When quantifying the degree of bacteriuria, a level of 103 - 105 CFU / ml is considered significant. In non-standard cases (with polyuria or immunosuppression), a lower degree of bacteriuria may be clinically significant.

In a general blood test, attention is paid to hematolotic signs of inflammation:

• neutrophilic leukocytosis with a shift of the formula to the left;
• elevated ESR.

A biochemical blood test allows you to clarify the functional state of the liver and kidneys.

Analysis for daily proteinuria and qualitative studies of excreted proteins are performed in controversial cases for differential diagnosis with primary glomerular kidney lesions.

Rehberg's test (glomerular filtration rate determination by endogenous creatinine clearance) is performed with minimal suspicion of CRF.

Examination for chronic pyelonephritis

Interrogation of the patient

During the survey, attention is paid to the characteristic episodes of pain in the lumbar region, accompanied by fever, the effectiveness of antibiotic therapy, as well as the symptoms of chronic renal failure (CRF) in history.

It is important to find out if the patient has:

• foci of chronic infection;
• anomalies of the kidneys and urinary tract;
• diseases that can cause a violation of the passage of urine;
• disorders of carbohydrate metabolism and the degree of their correction;
• immunodeficiency resulting from any disease or induced by drugs.

Important information about past inflammatory diseases of infectious etiology, the use of antibacterial drugs and their effectiveness. In pregnant women, it is necessary to find out the duration of pregnancy and the features of its course.

Physical examination

When examining a patient with chronic pyelonephritis, pay attention to:

• on pain on palpation in the kidney area;
• positive symptom of Pasternatsky on the affected side;
• the presence of polyuria (increased urine production).

Mandatory measurement of blood pressure, body temperature. A particular tendency to arterial hypertension is revealed in patients with secondary chronic pyelonephritis against the background of kidney anomalies.

Ultrasonography of the upper urinary tract should be performed to rule out urinary tract obstruction or urolithiasis.

Ultrasound can diagnose:

• swelling of the parenchyma during exacerbation;
• reduction in the size of the kidney, its deformation, increased echogenicity of the parenchyma (signs of nephrosclerosis) with long-term pyelonephritis without exacerbation;
• expansion of the pyelocaliceal system indicates a violation of the passage of urine.

Doppler study allows you to clarify the degree of violation of blood flow.

Further examination to clarify the diagnosis of chronic pyelonephritis in the active
stages individually for each patient.

Excretory urography reveals specific radiological signs of pyelonephritis. However, the main purpose of its implementation is to clarify the state of the urinary tract and diagnose violations of the passage of urine.

Early radiological signs of chronic pyelonephritis (CP) are a decrease in the tone of the upper urinary tract, flattening and rounding of the corners of the fornices, narrowing and elongation of the cups.

In the later stages, there is a sharp deformation of the cups, their convergence, pyelorenal
reflux, pyelectasis. Hodson's symptom and a decrease in the renal-cortical index are characteristic (detection of a decrease in the thickness of the kidney parenchyma at the poles in comparison with the thickness in the middle segment on excretory urograms). Normally, the thickness of the parenchyma (the distance from the outer contour of the kidney to the papillae of the pyramids) is 2.5 cm in the middle segment of the kidney, and 3-4 cm at the poles.

Radioisotope research methods are carried out to resolve the issue of the symmetry of nephropathy and assess the functional state of the kidney.

Voiding cystourethrography and/or radioisotope renography is used to detect vesicoureteral reflux and other changes in the lower urinary tract.

CT (Cromputer Imaging) and MRI (Magnetic Resonance Imaging) are indicated for the diagnosis of diseases that provoke the development of pyelonephritis:

• urolithiasis (CT, CT with contrast);
• tumors and anomalies in the development of the kidneys and urinary tract (CT with photocopying, MRI).

A kidney biopsy is used for differential diagnosis with other diffuse lesions of the renal tissue, especially when deciding on the need for immunosuppressive therapy.

With severe arterial hypertension and problems in the selection of antihypertensive therapy, it is important to perform a blood test for the content of renin, angiotensin and aldosterone.

If the patient remains feverish after 72 hours from the start of treatment, it is necessary to perform additional studies, such as spiral computed tomography, excretory urography or nephroscintigraphy.

Treatment of chronic pyelonephritis

It is necessary to eliminate or reduce the activity of the inflammatory process, which is possible only with the restoration of the outflow of urine and sanitation of the urinary tract.

Indications for hospitalization

With exacerbation of secondary pyelonephritis, emergency hospitalization in the urological department is indicated due to the potential need for surgical treatment.

With an exacerbation of primary non-obstructive pyelonephritis, antibiotic therapy can be started on an outpatient (home) basis; hospitalize only patients with complications or ineffective therapy.

Planned hospitalization is indicated in unclear cases for inpatient examination and in severe hypertension (high blood pressure) for additional research and selection of antihypertensive therapy.

Hospitalization is necessary if it is impossible to eliminate the factors complicating the course of the disease, available diagnostic methods and/or if the patient has clinical signs and symptoms of sepsis.

Drug treatment of chronic pyelonephritis

In the treatment of chronic pyelonephritis, antibacterial therapy plays a leading role. This disease can be caused by many types of microorganisms, against which any of the currently available antibacterial agents can be used.
drugs.

Treatment with antibacterial drugs for chronic pyelonephritis is preferably carried out after performing a bacteriological analysis of urine with the identification of the pathogen and determining its sensitivity to antibiotics.

Difficulties are caused by empirical (at random at the first visit) selection of drugs. Nevertheless, this type of therapy is rarely used in this disease (mainly with a sudden exacerbation of the disease).

There is a high resistance of the main pathogens of chronic pyelonephritis to a number of antibiotics, so ampicillin, amoxicillin, cephalosporins of the 1st line and nitroxalin are not included in the empirical therapy of uncomplicated urinary tract infections.

Given the sensitivity and resistance of microbes to antimicrobials for empirical therapy, oral 2-4th generation cephalosporins or fluoroquinolones, protected penicillins or aminopenicillins should be prescribed; aminoglycosides alone or in combination with beta-lactams.

Antibiotics for chronic pyelonephritis

Exacerbations of chronic pyelonephritis are treated with the same drugs as acute pyelonephritis. In case of exacerbation of chronic pyelonephritis or recurrence of acute uncomplicated pyelonephritis of mild to moderate severity, it is sufficient to prescribe oral therapy for 10-14 days (Table 2).

Mild to moderate pyelonephritis

Severe exacerbation of chronic pyelonephritis

Patients with relapse of acute uncomplicated severe pyelonephritis are treated with one of the following parenteral antibiotics (Table 3):

• parenteral fluoroquinolones in patients whose E. coli resistance to these drugs is
• 3rd generation cephalosporins in patients in whom the resistance index of S/1PC-producing E. coli strains to these drugs is
• aminopenicillins + inhibitors (β-lactamase with known sensitivity of gram-positive microorganisms to them;
• aminoglycosides or carbapenems in patients who have >10% E. coli resistance to fluoroquinolones and/or ESBL-producing E. coli strains to these drugs.

Table 3. Initial parenteral therapy for severe

* After improvement, the patient can be switched to oral administration of one of the above antibiotics (if active against the pathogen) to complete the 1-2 week course of treatment. Only the daily dose is indicated and no duration of therapy.
** Only with proven susceptibility, not for initial empiric therapy.

In case of exacerbation or recurrence of pyelonephritis, the appointment of antibiotic therapy is permissible only after the elimination of urinary passage disorders and should be accompanied by the eradication of correctable risk factors, if possible, removal or replacement of previously installed drains.

Surgical treatment of chronic pyelonephritis

In chronic pyelonephritis, surgical treatment is mainly aimed at restoring the passage of urine. With an exacerbation of this disease, which has passed into a purulent phase (apostematous nephritis or carbuncle of the kidney), decapsulation of the kidney and nephrostomy are indicated.

Indications for nephrectomy in chronic pyelonephritis

• pyonephrosis;
• severe unilateral nephrosclerosis with loss of organ function if the affected kidney becomes a focus of chronic infection;
• unilateral nephrosclerosis with loss or significant decrease in organ function if the affected kidney causes severe, difficult to control arterial hypertension.

Hypotensive therapy in chronic pyelonephritis is carried out according to the usual schemes. However, it should be noted that arterial hypertension in most cases is associated with an increase in the level of blood renin, therefore, basic drugs are considered ACE inhibitors. In case of intolerance (mainly due to cough), angiotensin II receptor antagonists will be the drugs of choice. Doses of drugs in such patients due to frequent nephrosclerosis (possibly bilateral) must be selected taking into account Reberg's test.

Phytotherapy of chronic pyelonephritis

In the complex therapy of chronic pyelonephritis, herbal remedies are used that have an anti-inflammatory, diuretic effect. Bearberry, lingonberry leaves have antimicrobial and diuretic effects. The latter is due to the presence of hydroquinone in lingonberry leaves. Cranberry juice, fruit drink (contains sodium benzoate) have an antiseptic effect (the synthesis in the liver from hippuric acid benzoate increases, which, excreted in the urine, gives a bacteriostatic effect). Take 2-4 glasses a day. It is considered appropriate for CP to prescribe a combination of herbs as follows: one diuretic and two bactericidal for 10 days (for example, cornflower flowers - lingonberry leaves - bearberry leaves), and then two diuretics and one bactericidal (for example, cornflower flowers - birch leaves - bearberry leaves ). Treatment medicinal plants it is carried out for a long time - for months and even years. In chronic pyelonephritis, it is necessary to maintain sufficient diuresis. The amount of liquid you drink should be 2000-2500 ml / day. The use of diuretic preparations, fortified decoctions (fruit drinks) with antiseptic properties is recommended.
(cranberries, lingonberries, rose hips). In the absence of exacerbations, long-term therapy with decoctions of diuretic and antiseptic herbs or official herbal preparations, such as: Cyston, Kanefron N, Phytolysin, Urolesan, etc.

In the case of accession of arterial hypertension, constant antihypertensive therapy is mandatory.

Diet for chronic pyelonephritis

Nutrition for chronic pyelonephritis should be complete, containing adequate amounts of proteins, fats, carbohydrates, vitamins and minerals. Patients with renal insufficiency are advised to limit the content of protein foods rich in purines in the diet.

Patients with chronic pyelonephritis complicated by arterial hypertension in the absence of polyuria and loss of electrolytes are shown to limit the intake of table salt (5-6 g / day) and liquid (up to 1000 ml / day).

The diet for chronic pyelonephritis includes the following foods:

• fish, meat and poultry of lean varieties (minced or boiled products);
• dairy and vegetarian soups (vegetable, fruit);
• dairy and sour-milk products (you can use mild cheeses, cottage cheese, milk, kefir, etc.);
• gray and white bread of yesterday's baking (preferably salt-free);
• flour products, puddings, cereals;
• eggs (1 piece per day);
• raw and boiled vegetables (with the exception of cauliflower, radish, radish, onion and garlic);
• greens (with the exception of celery, lettuce, sorrel and spinach);
• berries and fruits (strawberries, wild strawberries, pomegranates and other varieties rich in iron)
• gourds;
• vegetable oils (olive, sunflower);
• honey, jam, sugar.

All patients with chronic pyelonephritis should avoid spicy foods, smoked meats and marinades, minimize the amount of spices and seasonings in food.

With exacerbation of chronic pyelonephritis, the following diet is recommended:

• dairy products (milk, cottage cheese, etc.);
• boiled and mashed vegetables;
• fruits rich in potassium (raisins, apricots, dried apricots, etc.);
• flour and cereal dishes in moderation;
• salt-free white bread;
• sugar (no more than 50 g per day);
• butter (no more than 30 g).

The diet should be divided into 6 meals. Products should be well chopped, mashed or boiled until soft. It is necessary to include cranberry and lingonberry fruit drinks, a decoction of rose hips, green tea, jelly and compotes from dried fruits, herbal decoctions in the diet. In case of exacerbation of chronic pyelonephritis, it should be completely excluded from the diet:

• canned food, snacks, pickles and smoked meats;
• spicy seasonings and spices;
• alcoholic and carbonated drinks;
• rich broths;
• mushrooms and beans.

Non-drug treatment of chronic pyelonephritis

Non-drug treatment of chronic pyelonephritis is carried out only in remission after adequate antibiotic therapy and a noticeable improvement in the patient's condition. physiotherapy exercises in chronic pyelonephritis: to ensure proper blood circulation in the kidneys, improve the outflow of urine and reduce congestion in the urinary system. Cyclic views shown exercise moderate intensity: walking, jogging, skiing, rowing, which are especially widely used in sanatorium conditions. Massage for chronic pyelonephritis Massage the back, lumbar region, buttocks, abdomen and lower limbs using hyperemic ointments. Percussion is excluded. The duration of the massage is 8-10 minutes, the course is 10-15 procedures. Both manual massage and massage with brushes in the bath (water temperature not lower than 38 ° C) are shown, 2-3 procedures per week. A rather soft and small ball can be placed under the stomach in the region of the kidney and rolled with the control of the pressure force of the ball on the near-organ space of the kidney with the hands. Vacuum massage with cups in chronic pyelonephritis from one lobe of the embryo - the mesoderm, secondly, on the skin surface there are clearly marked representations of the kidneys (according to A.T. Ogulov), Zakharyin-Ged zones, Chinese medicine, topographic zones directly above the kidneys. When banks are exposed to these areas of the skin, the following processes occur: irritation of the reflex zone, which has a stimulating effect on the kidneys; a rush of blood and lymph from the underlying tissues, which has an effect on the blood and lymphatic vessels kidneys, congestion in the tissues is eliminated. Balneotherapy in chronic pyelonephritisThe effect of balneotherapy on the clinical and laboratory parameters of patients with chronic pancreatitis is known, under its influence an increase in the diuretic effect, anti-inflammatory effect, improvement of renal plasma flow and filtration of urine in the renal glomeruli are noted. 3-5 ml per 1 kg of body weight at one time, 4-6 times a day, 30-40 minutes before meals and 2 hours after meals, thermal temperature 38-40°C. The reactions of various systems under the influence of balneotherapy are aimed at stimulating adaptive-compensatory processes, mobilizing the reserve capabilities of functional, humoral, and metabolic processes, which is the essence of adaptation to the action of a physical factor. plasma flow, which improves the delivery of antibacterial agents to the kidneys; relieve spasm of smooth muscles of the renal pelvis and ureters, which contributes to the discharge of mucus, urinary crystals, bacteria. The following physiotherapy procedures are used:

• electrophoresis of drugs (furadonin, erythromycin, calcium chloride) on the kidney area. The course of treatment consists of 8-10 procedures;
• centimeter waves (“Luch-58”) on the kidney area, 6-8 procedures per course of treatment;
• thermal procedures on the area of ​​the diseased kidney: diathermy, therapeutic mud, diathermo mud, ozocerite and paraffin applications.

Outside of exacerbation, spa treatment is possible in Essentuki, Zhelezpovodsk, Pyatigorsk, Truskavets and at local resorts focused on the treatment of kidney diseases.

Home National Guidelines Pyelonephritis

Treatment and recovery

National guidelines for pyelonephritis

• Clinical guidelines for pyelonephritis
• Symptoms, diagnosis and treatment of acute pyelonephritis
• Symptoms, diagnosis and treatment of chronic pyelonephritis
• Acute pyelonephritis in children. Symptoms. Diagnostics. Treatment.
• Nephrology. National leadership
• Nephrology
• Nephrology. National leadership. Short edition

Pyelonephritis, the clinical recommendations for the treatment of which depend on the form of the disease, is an inflammatory disease of the kidneys. Factors affecting the occurrence of pyelonephritis: urolithiasis, irregular structure of the urinary canals, renal colic, prostate adenoma, etc.

Anyone can get kidney inflammation. However, girls aged 18 to 30 are at risk; older men; children under 7 years old. Doctors distinguish two forms of pyelonephritis: chronic and acute.

Symptoms, diagnosis and treatment of acute pyelonephritis

Acute pyelonephritis is an infectious disease of the kidneys. The disease develops quickly, literally within a few hours.

Symptoms of acute inflammation of the kidneys:

In case of symptoms, you should immediately contact a urologist or nephrologist and do not self-medicate! The doctor must conduct a diagnosis to confirm the diagnosis. The fact of acute inflammation of the kidneys will help to identify general urine and blood tests (the level of leukocytes will significantly exceed the norm) and ultrasound of the kidneys. The doctor may additionally prescribe an MRI or CT scan.

Acute pyelonephritis should be treated permanently. At the same time, it is necessary to eliminate not only the symptoms, but also the causes of the disease themselves. If treatment is not started on time, acute pyelonephritis can develop into chronic, and then completely into renal failure.

Therapeutic treatment of acute inflammation includes antibacterial drugs (antibiotics) and vitamins. In severe cases of inflammation, surgery may be necessary. In the first days of the disease, it is imperative to observe bed rest. At the same time, it is not even allowed to get up to use the toilet, which is why it is so important to undergo treatment in a hospital.

1. Stay warm. You can't overcool.
2. Drink plenty of fluids. An adult needs to drink more than 2 liters of fluid per day. Children - up to 1.5 liters. During this period, it is useful to drink sour citrus juices (grapefruit, orange, lemon). The fact is that the acidic environment kills bacteria, and the treatment process will be faster and easier.
3. Follow a diet. Exclude from the diet all fried, fatty, spicy, baked foods and bakery products. Dramatically reduce the use of salt and strong meat broths.
4. If all recommendations are followed, the treatment will take about 2 weeks. But a complete cure occurs after 6-7 weeks. Therefore, you can not stop drinking medicines. You need to complete the full course of treatment as prescribed by the doctor.

Sources

• http://med.domashniy-doktor.ru/index.php/%D0%BF%D0%BE%D1%87%D0%BA%D0%B8/240
• http://mbdou-ds49.ru/post_2968/
• http://stranacom.ru/article_2433/

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Other chronic tubulointerstitial nephritis (N11.8)

general information

Short description

Pyelonephritis is an inflammatory disease of the kidneys (or one kidney) of infectious origin with a predominant localization of the pathological process in the interstitial tissue and obligatory damage to the pelvicalyceal system.

Protocol code: H-T-039 "Chronic tubulointerstitial nephritis (Chronic pyelonephritis)"
For therapeutic hospitals

ICD codes:

N11 Chronic tubulointerstitial nephritis

N11 Tubulointerstitial nephritis, not specified as acute or chronic

N11.0 Non-obstructive chronic pyelonephritis associated with reflux

N11.1 Chronic obstructive pyelonephritis

N11.8, N14 Other tubulo-interstitial nephritis

Classification

Classification[A.V. Papayan, N.D. Savenkova, 1997]:

1. According to the ICD(see above)

2. By localization:
- one-sided;
- bilateral.

3. By the intactness of the kidneys:
- primary;
- secondary.

4. According to the state of kidney function- International Classification of Chronic Kidney Disease (CKD), K/DOQI:

- Stage I, GFR (glomerular filtration rate) - ≥ 90 ml/min.;

- II stage, GFR - 89-60 ml/min.;

- III stage, GFR - 59-30 ml/min.;

IV stage, GFR - 29-15 ml/min.;

Stage V, GFR - less than 15 ml/min (ESRD).

Diagnostics

Diagnostic criteria

Complaints and anamnesis:
- temperature rise;
- pain in the lumbar region;
- dysuria;

Episodes of gross hematuria;
- polyuria;
- weakness, malaise.

Physical examination:
- pain on palpation in the projection of the kidneys;

arterial hypertension.

Laboratory research:
- bacteriuria 10 5 ;
- leukocyturia;
- erythrocyturia;

Proteinuria (β2-microglobulin);
- decrease in the function of concentration;
- GFR;
- anemia.

Instrumental research:

Ultrasound of the kidneys: signs of urinary stagnation, congenital anomalies;

Cystography: vesicoureteral reflux or condition after antireflux surgery;

Nephroscintigraphy: lesions of the kidney parenchyma;

If the diagnosis is unclear: diagnostic puncture biopsy of the kidney.

Indications for expert advice:
- ENT doctor, dentist, gynecologist - for the rehabilitation of infections of the nasopharynx, oral cavity and external genitalia;
- Allergist - in case of allergy manifestations;
- ophthalmologist - to assess changes in microvessels;
- severe arterial hypertension, ECG disturbances, etc. are indications for consultation with a cardiologist;
- with signs of a systematic process - a rheumatologist;
- in the presence of viral hepatitis, zoonotic and intrauterine and other infections - infectious disease specialist.

List of main diagnostic measures:

Complete blood count (6 parameters), hematocrit;

Urine culture with selection of colonies and antibiogram;

Determination of creatinine, urea, uric acid;

Calculation of the glomerular filtration rate using the Cockcroft-Gault formula:
GFR, ml/min. \u003d (140 - age in years) x weight (kg) x coefficient / 0.82 x blood creatinine (µmol / l).
Coefficient: for women = 0.85; for men =1;

Determination of total protein, protein fractions;

Determination of ALT, AST, cholesterol, bilirubin, total lipids;

Determination of potassium/sodium, chlorides, iron, calcium, magnesium, phosphorus;

Study of the acid-base state;

ELISA for zoonotic infections;

General urine analysis;

Urinary protein electrophoresis (determination of beta2- and alpha1-microglobulin in urine);

Urinalysis according to Zimnitsky;

Ultrasound of the abdominal organs;

Dopplerometry of the vessels of the kidneys;

Scraping on helminth eggs;

Coprogram.

List of additional diagnostic measures:

Examination of feces for occult blood;

X-ray of the chest (one projection);

ECG, echocardiography;

Coagulogram 1 (prothrombin time, fibrinogen, thrombin time, APTT, plasma fibrinolytic activity);

Kidney biopsy with histological examination nephrobiopsy.

Differential Diagnosis

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Treatment

Treatment goals:
- elimination or reduction of the inflammatory process in the renal tissue (antibacterial therapy);
- symptomatic therapy - correction of arterial hypertension, homeostasis disorders, anemia;

Diuretic, nephroprotective therapy.

Non-drug treatment:
- diet number 5, with the exclusion from the diet of spicy dishes, rich soups, various flavoring seasonings, strong coffee;
- protective mode.

Medical treatment

Detoxification therapy:
- plentiful drink;
- parenteral infusion therapy in the form of solutions of glucose 5-10% and NaCl 0.45% is indicated only for dyspepsia (nausea, vomiting, diarrhea).

Antibacterial therapy
The main principle is the early and long-term administration of antimicrobial agents in strict accordance with the sensitivity of the microflora isolated from urine to them, the alternation of antibacterial drugs or their combined use. In addition, if possible, it is necessary to eliminate obstacles to the normal passage of urine.

1. Gram-positive flora: semi-synthetic penicillins (ampicillin, amoxicillin + clavulanic acid).
2. Gram-negative flora: co-trimoxazole + fluoroquines (ciprofloxacin, ofloxacin, norfloxacin).

3. Nosocomial infection: aminoglycosides (gentamicin) + cephalosporins (ceftriaxone, cefotaxime, ceftazidime).

4. Reserve antibiotics: imipenem, amikacin.

5. Uroantiseptics: nitrofurans (furagin).

The duration of antibiotic therapy is determined by the severity of the infectious process, the presence of complications.

In some cases, maintenance therapy with other antibacterial agents - uroseptics (furagin 1-2 mg / kg / night, co-trimoxazole - 120-240 mg at night) is necessary.
In parallel, it is necessary to carry out antifungal therapy (itraconazole), correction of intestinal microflora, therapy with immunostimulants.

In other cases of acute tubulointerstitial nephritis, treatment is symptomatic.

Medicinal nephritis requires the abolition of drugs, the causes of the disease, drinking plenty of water, sparing diet.

Preventive actions:

Prevention of viral, fungal infections;

Prevention of electrolyte imbalance;

Prevention of exacerbations.

Further management:
- control of filtration, concentration functions of the kidneys;

Control of urine tests;
- control of blood pressure;
- Ultrasound of the kidneys;
- nephroscintigraphy of the kidneys.
In the future, a combination of tubulointerstitial changes with glomerular ones (the appearance of edema, hypertension) is possible.

List of essential medicines:

1. Amoxicillin + clavulanic acid, film-coated tablets 250 mg/125 mg, 500 mg/125 mg, 875 mg/125 mg, powder for solution for intravenous administration in vials 500 mg / 100 mg

2. Ampicillin - 500 mg, vial

3. Ceftriaxone 500 mg, 1 g, vial

4. Imipenems

5. Fluoroquines (ciprofloxacin, ofloxacin, norfloxacin)
6. Co-trimoxazole - 120 mg, 480 mg, tab.

7. Cefuroxime axetil - 125 mg, 250 mg, tablets, suspensions

8. Gentamicin 40 mg, 80 mg, vial

9. Furagin 50 mg, tab.

10. Enalapril 5 mg, 10 mg, tab.

List of additional medicines:

1. Cefuroxime powder for solution for injection in a vial 750 mg, 1.5 g

CRP by quantitative method;

Creatinine, total protein, transaminases, thymol test and blood bilirubin;

Ultrasound of the kidneys.

Information

Sources and literature

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Borisov I. A., Sura V. V. Modern approaches to the problem of pyelonephritis // Ter. archive. 1982. No. 7. S. 125-135. 2. Mukhin N. A., Tareeva I. E. Diagnosis and treatment of kidney diseases. M., 1985. 3. Pytel A. Ya., Goligorsky S. D. Pyelonephritis. M., 1977. 4. Chizh AS Treatment of acute and chronic glomerulonephritis: Method, recommendations. Mn., 1982. 5. evidence-based medicine. Clinical recommendations for practitioners. 2nd edition, GEOTAR, 2002. 6. Kincaid Smith P. Pyelonephritis chronic, Interstitial. Nephritis and Obstructive Uropathy // Nephrology / Ed. Hambyrger et al. Paris, 1979. P. 553-582. 7. Grabensee B. Nephrologie. 2005 Stuttgart. New-York 8. Gilbert D. Guide to antimicrobial therapy. 2001. USA 9. K/DOQI clinical practice guidelines for chronic disease: evaluation, classification, and stratification. Kidney Disease Outcome Initiative. Am J Kidney Dis 2002 Feb;39 (2 Suppl 1): S1-246. 10. I International Nephrological Seminar "Actual Issues of Nephrology", Almaty, 2006. 11. A.Yu. Zemchenkov, N.A. Tomilina. "K/DOQI addresses the origins of chronic kidney disease". Nephrology and Dialysis, 2004, No. 3, pp. 204-220. 12. Clinical guidelines for practitioners based on evidence-based medicine. 2nd edition, GEOTAR, 2002
   2. The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
   3. The MedElement website and mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are exclusively information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
   4. The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

Pyelonephritis, the clinical recommendations for the treatment of which depend on the form of the disease, is an inflammatory disease of the kidneys. Factors affecting the occurrence of pyelonephritis: urolithiasis, irregular structure of the urinary canals, renal colic, prostate adenoma, etc.

Anyone can get kidney inflammation. However, girls aged 18 to 30 are at risk; older men; children under 7 years old. Doctors distinguish two forms of pyelonephritis: chronic and acute.

Symptoms, diagnosis and treatment of acute pyelonephritis

Acute pyelonephritis is an infectious disease of the kidneys. The disease develops quickly, literally within a few hours.

Symptoms of acute inflammation of the kidneys:

In case of symptoms, you should immediately contact a urologist or nephrologist and do not self-medicate! The doctor must conduct a diagnosis to confirm the diagnosis. The fact of acute inflammation of the kidneys will help to identify general urine and blood tests (the level of leukocytes will significantly exceed the norm) and ultrasound of the kidneys. The doctor may additionally prescribe an MRI or CT scan.

Acute pyelonephritis should be treated permanently. At the same time, it is necessary to eliminate not only the symptoms, but also the causes of the disease themselves. If treatment is not started on time, acute pyelonephritis can develop into chronic, and then completely into renal failure.

Therapeutic treatment of acute inflammation includes antibacterial drugs (antibiotics) and vitamins. In severe cases of inflammation, surgery may be necessary. In the first days of the disease, it is imperative to observe bed rest. At the same time, it is not even allowed to get up to use the toilet, which is why it is so important to undergo treatment in a hospital.

Symptoms, diagnosis and

According to statistics, about 20% of the world's population suffers from chronic pyelonephritis. It is an inflammatory disease of the kidneys that can develop from acute pyelonephritis, but mostly occurs as a separate disease.

Symptoms of chronic inflammation of the kidneys:

• frequent urination;
• an unreasonable increase in temperature not higher than 38 ° C, and usually in the evenings;
• slight swelling of the legs at the end of the day;
• slight swelling of the face in the morning;
• aching pain in the lower back;
• severe fatigue, often for no reason;
• increased blood pressure.

Blood and urine tests can confirm the diagnosis. In the general analysis of blood there will be low hemoglobin, and in the analysis of urine - increased leukocytes and bacteriuria. In a chronic disease, doing an ultrasound of the kidneys does not make sense - it will not show anything. It is important to understand that only a doctor can make a diagnosis. Self-medication is not worth it.

Chronic pyelonephritis can be treated at home, but only if the temperature and blood pressure do not rise, there is no nausea and vomiting, acute pain and suppuration. For treatment, the doctor must prescribe antibiotics and uroseptics. Therapeutic treatment lasts at least 14 days.

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During treatment, as in the case of acute inflammation, it is worth following the regimen:

• Rest as much as possible, do not burden the body. Lie down more, and in the first days of the illness, completely observe bed rest.
• Don't get cold.
• Drink about 3 liters of fluid per day. Cowberry or cranberry fruit drinks, fruit juices, mineral water without gas, rosehip broth are especially useful.
• Go to the toilet more often.
• At the time of treatment, stop drinking coffee and alcohol.
• Exclude mushrooms, legumes, smoked meats, marinades, spices from the diet.
• Reduce the amount of salt in food.

In the case of a chronic disease, traditional medicine will also help. It is worth drinking kidney herbs. Phytotherapy course - 2 times a year (in autumn and spring). The spa treatment with mineral waters will also have a therapeutic effect.

The main thing in the treatment of pyelonephritis is to identify the disease in time. In addition, in the future it is important not to overcool, drink plenty of fluids and maintain hygiene.

Hepatitis C: a short guide (the Flying Publisher Short Guide to Hepatitis C) 2011

If You Have Chronic Hepatitis B (CDC Information)

Living with Chronic Hepatitis C (CDC information)

EACS Clinical Protocol for the Management and Treatment of HIV Infection in Adults in Europe (EACS Practice Guide) 2010 Russian translation

ixodid Tick-borne Borreliosis in children and adults ( guidelines Research Institute of Children's Infections SPb) 2010 download

Medical Faculty

Leche bny faculty is the same age as the Altai State medical university, in 1954 the formation of the university began with it. It is the largest in terms of the number of students among all universities in the Altai Territory and one of the largest among medical universities in Russia. As a basic medical faculty, with its personnel and structural subdivisions, all newly opened faculties (improvement of doctors, pharmaceutical, dental, medical and preventive, higher nursing education) helped.

In the future, a subsequent one-year postgraduate specialization in internship is possible (surgery, internal medicine, obstetrics and gynecology, anesthesiology and intensive therapy, endocrinology, etc.), as well as residency and postgraduate studies.

Graduates of the Faculty of Medicine have successfully passed the final state certification in recent years and receive a doctor's diploma, which makes it possible in the future to choose more than 100 medical specialties.

In accordance with the Program of the Ministry of Health of the Russian Federation, the Medical Faculty of the State Budgetary Educational Institution of Higher Professional Education of the ASMU trains doctors in the specialty: 31.05.01 "General Medicine".

In connection with the transition to new educational standards, in which, in particular, the emphasis is shifted to increasing and improving the practical training of students, the faculty has developed, implemented and improved a special module for quantitative assessment of the quality of practical training of students, as well as the role (contribution) of each discipline ( departments). It consists of the following submodules: Book of accounting of practical skills (skills) of the student for the entire period of study in the specialty "Medicine". The results of the final self-assessment (self-assessment) of the LF graduate (according to the main, selected blocks of knowledge, skills). The matrix of responsibility and authority of the departments involved in the practical training of students, allowing to evaluate the contribution of each department. Computer control and analytical program for the dean's office to assess the knowledge and skills of students and the contribution of departments to the final level of mastering them (Certificate of state registration computer programs of the Federal Service for Protection and Intellectual Property No. 20106114917 dated July 28, 2010).

The main educational program in the specialty 31.05.01 "Medicine" of the medical faculty of our university over the past 5 years (2010; 2011; 2012, 2013 and 2014) is among the winners All-Russian competition"The Best Educational Programs of Innovative Russia"

In 2009, the jubilee graduation of the medical faculty took place, which for the fiftieth time joined the ranks of doctors in hospitals in the Altai Territory and beyond.

In 2014, the faculty, like our entire university, celebrated its 60th anniversary. Currently, about 90% of doctors in the Altai Territory are graduates of the ASMU, in particular, the medical faculty. Faculty graduates carry out professional activity in health care institutions of various forms of ownership, health authorities, professional educational institutions, research institutions, social protection institutions, etc. Our graduates successfully work in many regions of Russia and abroad in more than 15 countries of the world - Germany, Israel, the USA , Canada, Syria, India, Pakistan, Afghanistan, African countries and neighboring countries.

Information about the implemented level of education

at the Faculty of Medicine

For students in 1-6 courses - Federal State educational standard (FSES, 2016)

Direction of training- "Medicine" 35.05.01

Qualification (degree) of the graduate- general doctor

Diploma specialty- "Medicine"

Training period- 6 years

More than 2 thousand people, including more than 100 foreign students, study at the six courses of the Faculty of Medicine. Graduates are being accepted and trained on a contractual basis from the republics of Altai, Tuva and neighboring countries: Tajikistan, Kazakhstan, Uzbekistan, Azerbaijan, Ukraine, as well as other countries - Syria, China, Mongolia, Iraq, Egypt, Nigeria, Morocco and others. Training of foreign citizens begins with the 1st course in the language of the intermediary - English.

Chronic pyelonephritis

• What is chronic pyelonephritis
• Treatment of chronic pyelonephritis

What is chronic pyelonephritis

Chronic pyelonephritis is the result of untreated or undiagnosed acute pyelonephritis. It is considered possible to talk about chronic pyelonephritis already in those cases when recovery after acute pyelonephritis does not occur within 2-3 months. The literature discusses the possibility of primary chronic pyelonephritis, i.e., without a history of acute pyelonephritis. This explains, in particular, the fact that chronic pyelonephritis is more common than acute. However, this opinion is not sufficiently substantiated and is not recognized by everyone.

Pathogenesis (what happens?) during Chronic pyelonephritis

In a pathomorphological study in patients with chronic pyelonephritis, a decrease in one or both kidneys is macroscopically detected, as a result of which, in most cases, they differ in size and weight. Their surface is uneven, with areas of retraction (at the site of cicatricial changes) and protrusion (at the site of unaffected tissue), often coarsely bumpy. The fibrous capsule is thickened, it is difficult to separate from the renal tissue due to numerous adhesions. On the surface of the incision of the kidney, areas of scar tissue of a grayish color are visible. In the advanced stage of pyelonephritis, the mass of the kidney decreases to 40-60 g. The cups and pelvis are somewhat dilated, their walls are thickened, and the mucosa is sclerosed.

A characteristic morphological feature of chronic pyelonephritis, as well as acute, is focality and polymorphism of renal tissue damage: along with areas of healthy tissue, there are foci of inflammatory infiltration and zones of cicatricial changes. The inflammatory process primarily affects the interstitial tissue, then the renal tubules are involved in the pathological process, the atrophy and death of which occurs due to infiltration and sclerosis of the interstitial tissue. And first, the distal and then the proximal parts of the tubules are damaged and die. The glomeruli are involved in the pathological process only in the late (terminal) stage of the disease; therefore, the decrease in glomerular filtration occurs much later than the development of concentration deficiency. Relatively early, pathological changes develop in the vessels and manifest themselves in the form of endarteritis, hyperplasia of the middle membrane and sclerosis of arterioles. These changes lead to a decrease in renal blood flow and the occurrence of arterial hypertension.

Morphological changes in the kidneys usually increase slowly, which determines the long-term duration of this disease. Due to the earliest and predominant damage to the tubules and a decrease in the concentration ability of the kidneys, diuresis persists for many years with a low, and then with a monotonous relative density of urine (hypo- and isohyposthenuria). Glomerular filtration, on the other hand, remains at a normal level for a long time and decreases only in the late stage of the disease. Therefore, compared with chronic glomerulonephritis, the prognosis in patients with chronic pyelonephritis in relation to life expectancy is more favorable.

Symptoms of chronic pyelonephritis

The course and clinical picture of chronic pyelonephritis depend on many factors, including the localization of the inflammatory process in one or both kidneys (unilateral or bilateral), the prevalence of the pathological process, the presence or absence of an obstruction to the flow of urine in the urinary tract, the effectiveness of previous treatment, the possibility of concomitant diseases .

Clinical and laboratory signs of chronic pyelonephritis are most pronounced in the phase of exacerbation of the disease, and insignificant during remission, especially in patients with latent pyelonephritis. In primary pyelonephritis, the symptoms of the disease are less pronounced than in secondary pyelonephritis. Exacerbation of chronic pyelonephritis may resemble acute pyelonephritis and be accompanied by fever, sometimes up to 38-39 ° C, pain in the lumbar region (on one or both sides), dysuric phenomena, deterioration in general condition, loss of appetite, headache, often (more often in children ) abdominal pain, nausea and vomiting.

During an objective examination of the patient, puffiness of the face, pastosity or swelling of the eyelids, more often under the eyes, especially in the morning after sleep, pallor of the skin can be noted; positive (although not always) Pasternatsky's symptom on one side (left or right) or on both sides with bilateral pyelonephritis. In the blood, leukocytosis and an increase in ESR are detected, the severity of which depends on the activity of the inflammatory process in the kidneys. Leukocyturia, bacteriuria, proteinuria appear or increase (usually not exceeding 1 g / l and only in some cases reaching 2.0 g or more per day), in many cases active leukocytes are detected. There is moderate or severe polyuria with hypostenuria and nocturia. The above symptoms, especially if there is a history of indications of acute pyelonephritis, makes it relatively easy, timely and correctly to determine the diagnosis of chronic pyelonephritis.

More significant diagnostic difficulties are pyelonephritis during remission, especially primary and latent course. In such patients, pain in the lumbar region is minor and intermittent, aching or pulling. Dysuric phenomena in most cases are absent or are observed occasionally and are not very pronounced. The temperature is usually normal and only sometimes (more often in the evenings) rises to subfebrile numbers (37-37.1 ° C). Proteinuria and leukocyturia are also minor and intermittent. The concentration of protein in the urine ranges from traces to 0.033-0.099 g / l. The number of leukocytes in repeated urine tests does not exceed the norm or reaches 6-8, less often 10-15 in the field of view. Active leukocytes and bacteriuria in most cases are not detected. Often there is a slight or moderate anemia, a slight increase in ESR.

With a long course of chronic pyelonephritis, patients complain of increased fatigue, decreased performance, loss of appetite, weight loss, lethargy, drowsiness, headaches periodically occur. Later, dyspeptic phenomena, dryness and peeling of the skin join. The skin acquires a peculiar grayish-yellow color with an earthy tint. The face is puffy, with constant pastiness of the eyelids; the tongue is dry and covered with a dirty brown coating, the mucous membrane of the lips and mouth is dry and rough. In 40-70% of patients with chronic pyelonephritis (V. A. Pilipenko, 1973), as the disease progresses, symptomatic arterial hypertension develops, reaching a high level in some cases, especially diastolic pressure (180/115-220/140 mm Hg) . Approximately in 20-25% of patients, arterial hypertension joins already in the initial stages (in the first years) of the disease. There is no doubt that the addition of hypertension not only changes the clinical picture of the disease, but also aggravates its course. As a consequence of hypertension, hypertrophy of the left ventricle of the heart develops, often with signs of its overload and ischemia, clinically accompanied by attacks of angina pectoris. Possible hypertensive crises with left ventricular failure, dynamic violation of cerebral circulation, and in more severe cases - with strokes and thrombosis of cerebral vessels. Symptomatic antihypertensive therapy is ineffective if the pyelonephritic genesis of arterial hypertension is not established in a timely manner and anti-inflammatory treatment is not carried out.

In the later stages of pyelonephritis, bone pain, polyneuritis, and hemorrhagic syndrome occur. Edema is not typical and is practically not observed.

For chronic pyelonephritis in general and in the later stages, polyuria is especially characteristic with the release of up to 2-3 liters or more of urine during the day. Cases of polyurine reaching 5-7 liters per day are described, which can lead to the development of hypokalemia, hyponatremia and hypochloremia; polyuria is accompanied by pollakiuria and nocturia, hypostenuria. As a result of polyuria, thirst and dry mouth appear.

The symptoms of chronic primary pyelonephritis are often so poor that the diagnosis is made very late, when signs of chronic renal failure are already observed, or when arterial hypertension is accidentally detected and its origin is tried to be established. In some cases, a peculiar complexion, dry skin and mucous membranes, taking into account complaints of an asthenic nature, make it possible to suspect chronic pyelonephritis.

Diagnosis of chronic pyelonephritis

Establishing the diagnosis of chronic pyelonephritis is based on the complex use of data from the clinical picture of the disease, the results of clinical and laboratory, biochemical, bacteriological, ultrasound, X-ray urological and radioisotope studies, and, if necessary and possible, data from a puncture biopsy of the kidney. An important role belongs to a carefully collected anamnesis. Indications in the anamnesis of past cystitis, urethritis, pyelitis, renal colic, the passage of stones, as well as anomalies in the development of the kidneys and urinary tract are always significant factors in favor of chronic pyelonephritis.

The greatest difficulties in the diagnosis of chronic pyelonephritis arise in its latent, latent course, when the clinical signs of the disease are either absent or so slightly pronounced and not characteristic that they do not allow a convincing diagnosis. Therefore, the diagnosis of chronic pyelonephritis in such cases is based mainly on the results of laboratory, instrumental and other research methods. In this case, the leading role is given to the study of urine and the detection of leukocyturia, proteinuria and bacteriuria.

Proteinuria in chronic pyelonephritis, as in acute pyelonephritis, is usually insignificant and does not exceed, with rare exceptions, 1.0 g / l (usually from traces to 0.033 g / l), and the daily excretion of protein in the urine is less than 1.0 g. Leukocyturia can be of varying severity, but more often the number of leukocytes is 5-10, 15-20 per field of view, rarely reaches 50-100 or more. Occasionally, isolated hyaline and granular casts are found in the urine.

In patients with a latent course of the disease, proteinuria and leukocyturia may not be present at all during a routine urinalysis in separate or several tests, so it is necessary to conduct urine tests in dynamics repeatedly, including according to Kakovsky-Addis, Nechiporenko, for active leukocytes, as well as seeding urine on the microflora and the degree of bacteriuria. If the protein content in the daily amount of urine exceeds 70-100 mg, the number of leukocytes in the sample according to Kakovsky-Addis is more than 4. 106 / day, and in the study according to Nechiporenko - more than 2.5. 106 / l, then this may speak in favor of pyelonephritis.

The diagnosis of pyelonephritis becomes more convincing if active leukocytes or Sternheimer-Malbin cells are found in the urine of patients. However, their importance should not be overestimated, since it has been established that they are formed at a low osmotic pressure of urine (200-100 mosm / l) and again turn into ordinary leukocytes with an increase in the osmotic activity of urine. Therefore, these cells may be the result of not only an active inflammatory process in the kidneys, but also the result of a low relative density of urine, which is often observed in pyelonephritis. However, if the number of active leukocytes is more than 10-25% of all leukocytes excreted in the urine, then this not only confirms the presence of pyelonephritis, but also indicates its active course (M. Ya. Ratner et al. 1977).

An equally important laboratory sign of chronic pyelonephritis is bacteriuria, exceeding 50-100 thousand in 1 ml of urine. It can be detected in various phases of this disease, but more often and more significant during the period of exacerbation. It has now been proven that the so-called physiological (or false, isolated, without inflammatory process) bacteriuria does not exist. Long-term follow-up of patients with isolated bacteriuria, without other signs of damage to the kidneys or urinary tract, showed that some of them develop a full clinical picture of pyelonephritis over time. Therefore, the terms "bacteriuria" and even more so "urinary tract infection" should be treated with caution, especially in pregnant women and children. Although isolated bacteriuria does not always lead to the development of pyelonephritis, however, to prevent it, some authors recommend treating each such patient until urine is completely sterile (I. A. Borisov, V. V. Sura, 1982).

With asymptomatic, latent and atypically occurring forms of chronic pyelonephritis, when the methods of urine examination mentioned above are not convincing enough, provocative tests (in particular, prednisone) are also used to temporarily activate the latent current inflammatory process in the kidneys.

In chronic pyelonephritis, even primary, hematuria is also possible, mainly in the form of microhematuria, which, according to V. A. Pilipenko (1973), occurs in 32.3% of cases. Some authors (M. Ya. Ratner, 1978) distinguish the hematuric form of pyelonephritis. Gross hematuria sometimes accompanies calculous pyelonephritis or develops as a result of a destructive process in the vault of the cup (fornic bleeding).

In the peripheral blood, anemia, an increase in ESR are more often detected, less often - a slight leukocytosis with a neutrophilic shift of the leukocyte formula to the left. In the proteinogram of the blood, especially in the acute phase, there are pathological changes with hypoalbuminemia, hyper-a1- and a2-globulinemia, in the late stages with hypogammaglobulinemia.

In contrast to chronic glomerulonephritis, in chronic pyelonephritis, it is not glomerular filtration that first decreases, but the concentration function of the kidneys, resulting in often observed polyuria with hypo- and isosthenuria.

Violations of electrolyte homeostasis (hypokalemia, hyponatremia, hypocalcemia), which sometimes reach significant severity, are due to polyuria and a large loss of these ions in the urine.

In the advanced stage of chronic pyelonephritis, glomerular filtration is significantly reduced, as a result, the concentration of nitrogenous wastes - urea, creatinine, residual nitrogen - increases in the blood. However, transient hyperazotemia can also occur during an exacerbation of the disease. In such cases, under the influence of successful treatment, the nitrogen excretion function of the kidneys is restored and the level of creatinine and urea in the blood is normalized. Therefore, the prognosis for the appearance of signs of chronic renal failure in patients with pyelonephritis is more favorable than in patients with chronic glomerulonephritis.

An essential role in the diagnosis of chronic pyelonephritis, especially secondary, is played by ultrasound and X-ray methods of investigation. The unequal sizes of the kidneys, the unevenness of their contours, the unusual location can be detected even on a plain radiograph and with the help of ultrasound. More detailed information about the violation of the structure and function of the kidneys, pyelocaliceal system and upper urinary tract can be obtained using excretory urography, especially infusion. The latter gives clearer results even with a significant violation of the excretory function of the kidneys. Excretory urography allows you to identify not only changes in the size and shape of the kidneys, their location, the presence of stones in the cups, pelvis or ureters, but also to judge the state of the total excretory function of the kidneys. Spasm or club-shaped expansion of the cups, a violation of their tone, deformation and expansion of the pelvis, changes in the shape and tone of the ureters, anomalies in their development, strictures, expansion, kinks, torsion and other changes testify in favor of pyelonephritis.

In the later stages of the disease, when wrinkling of the kidneys occurs, a decrease in their size (or one of them) is also detected. At this stage, the impairment of kidney function reaches a significant degree and the excretion of the contrast agent sharply slows down and decreases, and sometimes is completely absent. Therefore, with severe renal insufficiency, it is not advisable to carry out excretory urography, since contrasting of the renal tissue and urinary tract is sharply reduced or does not occur at all. In such cases, when urgently needed, resort to infusion urography or retrograde pyelography, as well as with unilateral obturation of the ureter with a violation of the outflow of urine. If the contours of the kidneys are not clearly detected during survey and excretory urography, and also if a kidney tumor is suspected, pneumorethroperitoneum (pneumoren) and computed tomography are used.

Significant assistance in the complex diagnosis of pyelonephritis is provided by radioisotope methods - renography and kidney scanning. However, their differential diagnostic value is relatively small compared to X-ray examination, since the dysfunction and changes in the structure of the kidneys detected with their help are non-specific and can be observed in other kidney diseases, and renography, in addition, also gives a high percentage of diagnostic errors. These methods make it possible to establish a dysfunction of one of the kidneys compared to the other and, therefore, are of great importance in the diagnosis of secondary and unilateral pyelonephritis, while in primary pyelonephritis, which is more often bilateral, their diagnostic value is small. However, in the complex diagnosis of chronic pyelonephritis, especially when, for one reason or another (allergy to a contrast agent, significant impairment of kidney function, etc.), excretory urography is impossible or contraindicated, radioisotope research methods can be of great help.

For the diagnosis of unilateral pyelonephritis, as well as to clarify the genesis of arterial hypertension in large diagnostic centers, renal angiography is also used.

Finally, if it is still not possible to accurately establish the diagnosis, intravital puncture biopsy of the kidney is indicated. However, it should be borne in mind that this method does not always allow to confirm or exclude the diagnosis of pyelonephritis. According to I. A. Borisov and V. V. Sura (1982), with the help of a puncture biopsy, the diagnosis of pyelonephritis can be confirmed only in 70% of cases. This is explained by the fact that in pyelonephritis, pathological changes in the renal tissue are focal in nature: healthy tissue is located next to the areas of inflammatory infiltration, the penetration of a puncture needle into which gives negative results and cannot confirm the diagnosis of pyelonephritis if it is unquestionably present. Therefore, only positive results of a puncture biopsy, i.e. confirming the diagnosis of pyelonephritis, have diagnostic value.

Chronic pyelonephritis must be differentiated primarily from chronic glomerulonephritis, renal amyloidosis, diabetic glomerulosclerosis and hypertension.

Amyloidosis of the kidneys in the initial stage, manifested only by slight proteinuria and very poor urinary sediment, can simulate a latent form of chronic pyelonephritis. However, unlike pyelonephritis, leukocyturia is absent in amyloidosis, active leukocytes and bacteriuria are not detected, the concentration function of the kidneys remains at a normal level, there are no radiographic signs of pyelonephritis (the kidneys are the same, of normal size or somewhat enlarged). In addition, secondary amyloidosis is characterized by the presence of long-term chronic diseases, more often pyoinflammatory.

Diabetic glomerulosclerosis develops in patients with diabetes mellitus, especially with its severe course and long duration of the disease. At the same time, there are other signs of diabetic angiopathy (changes in the vessels of the retina, lower extremities, polyneuritis, etc.). There are no dysuric phenomena, leukocyturia, bacteriuria and radiographic signs of pyelonephritis.

Chronic pyelonephritis with symptomatic hypertension, especially with a latent course, is often mistakenly assessed as hypertension. Differential diagnosis of these diseases presents great difficulties, especially in the terminal stage.

If from the anamnesis or medical documentation it is possible to establish that changes in the urine (leukocyturia, proteinuria) preceded (sometimes for many years) the onset of hypertension, or cystitis, urethritis, renal colic were observed long before its development, calculi were found in the urinary tract, then the symptomatic origin of hypertension as a consequence of pyelonephritis is usually beyond doubt. In the absence of such indications, it should be taken into account that hypertension in patients with chronic pyelonephritis is characterized by higher diastolic pressure, stability, insignificant and unstable effectiveness of antihypertensive drugs and a significant increase in their effectiveness if they are used in combination with antimicrobial agents. Sometimes, at the beginning of the development of hypertension, only anti-inflammatory therapy is sufficient, which, without antihypertensive drugs, leads to a decrease or even stable normalization of blood pressure. Often you have to resort to the study of urine according to Kakovsky-Addis, for active leukocytes, urine culture for microflora and the degree of bacteriuria, pay attention to the possibility of unmotivated anemia, an increase in ESR, a decrease in the relative density of urine in the Zimnitsky sample, which are characteristic of pyelonephritis.

In favor of pyelonephritis, some data from ultrasound and excretory urography (deformation of the cups and pelvis, stricture or atony of the ureters, nephroptosis, unequal sizes of the kidneys, the presence of calculi, etc.), radioisotope renography (decreased function of one kidney with preserved function of the other) and renal angiography (narrowing, deformation and reduction in the number of small and medium-sized arteries). If the diagnosis is in doubt even after all the above methods of research, it is necessary (if possible and in the absence of contraindications) to resort to a puncture biopsy of the kidneys.

Treatment of chronic pyelonephritis

It should be comprehensive, individual and include a regimen, diet, medications and measures aimed at eliminating the causes that prevent the normal passage of urine.

Patients with chronic pyelonephritis during the period of exacerbation of the disease need inpatient treatment. At the same time, as in acute pyelonephritis, it is advisable to hospitalize patients with secondary pyelonephritis in urological departments, and with primary - in therapeutic or specialized nephrological departments. They are prescribed bed rest, the duration of which depends on the severity of the clinical symptoms of the disease and their dynamics under the influence of the treatment.

An obligatory component of complex therapy is a diet that provides for the exclusion from the diet of spicy dishes, rich soups, various flavoring seasonings, and strong coffee. Food should be sufficiently high-calorie (2000-2500 kcal), contain the physiologically necessary amount of basic ingredients (proteins, fats, carbohydrates), well fortified. These requirements are best met by a dairy-vegetarian diet, as well as meat, boiled fish. In the daily diet, it is advisable to include dishes from vegetables (potatoes, carrots, cabbage, beets) and fruits (apples, plums, apricots, raisins, figs), rich in potassium and vitamins C, P, group B, milk and dairy products, eggs.

Since with rare exceptions, edema is absent in chronic pyelonephritis, the liquid can be taken without restriction. It is desirable to use it in the form of various fortified drinks, juices, fruit drinks, compotes, kissels, as well as mineral water, cranberry juice is especially useful (up to 1.5-2 liters per day). Fluid restriction is necessary in cases where an exacerbation of the disease is accompanied by a violation of the outflow of urine or arterial hypertension, which requires a more severe restriction of sodium chloride (up to 4-6 g per day), while in the absence of hypertension during an exacerbation, up to 6-8 g, and with a latent course - up to 8-10 g. Patients with anemia are shown foods rich in iron and cobalt (apples, pomegranates, strawberries, strawberries, etc.). In all forms and at any stage of pyelonephritis, it is recommended to include watermelons, melons, pumpkins in the diet, which have a diuretic effect and help cleanse the urinary tract from microbes, mucus, and small stones.

Crucial in the treatment of chronic pyelonephritis, as well as acute, belongs to antibacterial therapy, the basic principle of which is the early and long-term administration of antimicrobial agents in strict accordance with the sensitivity of the microflora isolated from urine to them, the alternation of antibacterial drugs or their combined use. Antibacterial therapy is ineffective if it is started late, is not carried out actively enough, without taking into account the sensitivity of the microflora, and if the obstacles to the normal passage of urine are not eliminated.

In the late stage of pyelonephritis, due to the development of sclerotic changes in the kidneys, a decrease in renal blood flow and glomerular filtration, it is not possible to achieve the required concentration of antibacterial drugs in the renal tissue, and the effectiveness of the latter drops markedly even at high doses. In turn, due to a violation of the excretory function of the kidneys, there is a danger of cumulation of antibiotics introduced into the body and the risk of severe side effects increases, especially when large doses are prescribed. With late-started antibiotic therapy and insufficiently active treatment, it becomes possible to develop antibiotic-resistant strains of microbes and microbial associations with different susceptibility to the same antimicrobial drug.

For the treatment of pyelonephritis, antibiotics, sulfonamides, nitrofurans, nalidixic acid, b-NOC, bactrim (biseptol, septrin) are used as antimicrobial agents. Preference is given to the drug to which the microflora is sensitive and which is well tolerated by patients. Penicillin drugs have the least nephrotoxicity, especially semi-synthetic penicillins (oxacillin, ampicillin, etc.), oleandomycin, erythromycin, levomycetin, cephalosporins (kefzol, tseporin). Nitrofurans, nalidixic acid (negram, nevigramon), 5-NOC are distinguished by slight nephrotoxicity. Aminoglycosides (kanamycin, colimycin, gentamicin) have high nephrotoxicity, which should be prescribed only in severe cases and for a short period (5-8 days), in the absence of the effect of other antibiotics to which the microflora turned out to be resistant.

When prescribing antibiotics, it is also necessary to take into account the dependence of their activity on urine pH. For example, gentamicin and erythromycin are most effective in alkaline urine (pH 7.5-8.0), therefore, when they are prescribed, a milk-vegetable diet, the addition of alkalis (baking soda, etc.), the use of alkaline mineral water (Borjomi, etc.) .). Ampicillin and 5-NOC are most active at pH 5.0-5.5. Cephalosporins, tetracyclines, chloramphenicol are effective in both alkaline and acidic urine reactions (ranging from 2.0 to 8.5-9.0).

During the period of exacerbation, antibiotic therapy is carried out for 4-8 weeks - until the elimination of clinical and laboratory manifestations of the activity of the inflammatory process. In severe cases, they resort to various combinations of antibacterial drugs (an antibiotic with sulfonamides or furagin, 5-NOC, or a combination of all together); shows their parenteral administration, often intravenously and in large doses. An effective combination of penicillin and its semi-synthetic analogues with nitrofuran derivatives (furagin, furadonin) and sulfonamides (urosulfan, sulfadimethoxine). Nalidixic acid preparations can be combined with all antimicrobial agents. To them, the least resistant strains of microbes are observed. Effective, for example, the combination of carbenicillin or aminoglycosides with nalidixic acid, the combination of gentamicin with cephalosporins (preferably with kefzol), cephalosporins and nitrofurans; penicillin and erythromycin, as well as antibiotics with 5-NOC. The latter is currently considered one of the most active uroseptics with a wide spectrum of action. Levomycetin succinate 0.5 g 3 times a day intramuscularly is very effective, especially with gram-negative flora. Gentamycin (garamycin) finds widespread use. It has a bactericidal effect on Escherichia coli and other Gram-negative bacteria; it is also active against gram-positive microbes, in particular against penicillinase-forming staphylococcus aureus and b-hemolytic streptococcus. The high antibacterial effect of gentamicin is due to the fact that 90% of it is excreted unchanged by the kidneys, and therefore a high concentration of this drug is created in the urine, which is 5-10 times higher than the bactericidal one. It is prescribed 40-80 mg (1-2 ml) 2-3 times a day intramuscularly or intravenously for 5-8 days.

The number of antibacterial drugs currently used for the treatment of pyelonephritis is large and increases every year, so it is not possible and necessary to dwell on the characteristics and effectiveness of each of them. The doctor prescribes this or that drug individually, taking into account the above basic principles of therapy for chronic pyelonephritis.

The criteria for the effectiveness of the treatment are the normalization of temperature, the disappearance of dysuric phenomena, the return to normal values ​​of peripheral blood (leukocyte count, ESR), the persistent absence or at least a noticeable decrease in proteinuria, leukocyturia and bacteriuria.

Since even after successful treatment, frequent (up to 60-80%) relapses of the disease are observed, it is generally accepted to carry out many months of anti-relapse therapy. It is necessary to prescribe various antimicrobial drugs, sequentially alternating them, taking into account the sensitivity of the microflora to them and under control of the dynamics of leukocyturia, bacteriuria and proteinuria. There is still no consensus on the duration of such treatment (from 6 months to 1-2 years).

Various schemes of intermittent treatment on an outpatient basis have been proposed. The most widely used is the scheme, according to which, for 7-10 days of each month, various antimicrobial agents are alternately prescribed (an antibiotic, for example, levomycetin, 0.5 g 4 times a day, next month, a sulfanilamide drug, for example, urosulfan or etazol, in subsequent months - furagin, nevigramon, 5-NOC, changing every month). Then the treatment cycle is repeated.

In the intervals between medications, it is recommended to take decoctions or infusions of herbs that have a diuretic and antiseptic effect (cranberry juice, rosehip broth, horsetail grass, juniper fruits, birch leaves, bearberry, lingonberry leaf, celandine leaves and stems, etc.). For the same purpose, you can use nikodin (within 2-3 weeks), which has moderate antibacterial activity, especially with concomitant cholecystitis.

In some cases, the treatment of chronic pyelonephritis with antibacterial agents may be accompanied by allergic and other side effects, and therefore antihistamines (diphenhydramine, pipolfen, tavegil, etc.) are indicated to reduce or prevent them. Sometimes you have to completely abandon them and resort to cylotropin, urotropin, salol. With prolonged treatment with antibiotics, it is advisable to prescribe vitamins.

Patients with arterial hypertension are shown antihypertensive drugs (reserpine, adelfan, hemiton, clonidine, dopegyt, etc.) in combination with saluretics (hypothiazid, furosemide, triampur, etc.). In the presence of anemia, in addition to iron preparations, vitamin B12, folic acid, anabolic hormones, transfusion of erythrocyte mass, whole blood is indicated (with significant and persistent anemia).

According to the indications, complex therapy includes cardiac glycosides - corglicon, strophanthin, celanide, digoxin, etc.

In patients with secondary pyelonephritis, along with conservative therapy, they often resort to surgical methods of treatment in order to eliminate the cause of urinary stasis (especially with calculous pyelonephritis, prostate adenoma, etc.).

An important place in the complex therapy of chronic pyelonephritis is sanatorium treatment, mainly in patients with secondary (calculous) pyelonephritis after surgery for the removal of stones. The most indicated stay in balneo-drinking sanatoriums is Truskavets, Zheleznovodsk, Sairme, Berezovskie Mineralnye Vody. Abundant drinking of mineral water helps to reduce the inflammatory process in the kidneys and urinary tract, "wash out" of them mucus, pus, microbes and small stones, improves the general condition of patients.

Patients with high arterial hypertension and severe anemia, with symptoms of renal failure, spa treatment is contraindicated. Patients with chronic pyelonephritis should not be sent to climatic resorts, since the effect of this is usually not observed.

Prevention of chronic pyelonephritis

Measures for the prevention of chronic pyelonephritis are the timely and thorough treatment of patients with acute pyelonephritis, dispensary observation and examination of this contingent of patients, their proper employment, as well as the elimination of causes that prevent the normal outflow of urine, in the treatment of acute diseases of the bladder and urinary tract; in the rehabilitation of chronic foci of infection.

In chronic primary pyelonephritis, the recommendations for the employment of patients are the same as for chronic glomerulonephritis, i.e., patients can perform work that is not associated with great physical and nervous stress, with the possibility of hypothermia, prolonged stay on their feet, in night shifts, in hot workshops.

Diet, diet are the same as in acute pyelonephritis. In the presence of symptomatic hypertension, more severe salt restriction is required, as well as some fluid restriction, especially in cases where there is edema or a tendency to edema. In order to prevent exacerbations of pyelonephritis and its progression, various schemes for long-term therapy of this disease have been proposed.

In secondary acute or chronic pyelonephritis, the success of both inpatient and long-term outpatient treatment largely depends on the elimination of the causes that lead to impaired urine outflow (calculi, ureteral strictures, prostate adenoma, etc.). Patients should be under the supervision of a urologist or a nephrologist (therapist) and a urologist.

In the prevention of recurrence of chronic pyelonephritis, its further progression and the development of chronic renal failure, timely detection and careful treatment of hidden or obvious foci of infection, as well as intercurrent diseases, are important.

Patients who have had acute pyelonephritis after discharge from the hospital should be registered with the dispensary and observed for at least one year, subject to normal urine tests and in the absence of bacteriuria. If proteinuria, leukocyturia, bacteriuria persist or periodically appear, the dispensary observation period is increased to three years from the onset of the disease, and then, in the absence of a complete treatment effect, patients are transferred to a group with chronic pyelonephritis.

Patients with chronic primary pyelonephritis need constant long-term dispensary observation with periodic inpatient treatment in case of exacerbation of the disease or an increasing decline in kidney function.

In acute pyelonephritis after a course of treatment in a hospital, patients are subject to a dispensary examination once every two weeks in the first two months, and then once every one to two months during the year. Urine tests are mandatory - general, according to Nechiporenko, for active leukocytes, for the degree of bacteriuria, for microflora and its sensitivity to antibacterial agents, as well as a general blood test. Once every 6 months, the blood is examined for the content of urea, creatinine, electrolytes, total protein and protein fractions, glomerular filtration is determined, urinalysis according to Zimnitsky, if necessary, a consultation with a urologist and X-ray urological examinations are indicated.

In patients with chronic pyelonephritis in the inactive phase, the same amount of research as in acute pyelonephritis should be carried out once every six months.

With the appearance of signs of chronic renal failure, the terms of dispensary examinations and examinations are significantly reduced as it progresses. Particular attention is paid to the control of blood pressure, the state of the fundus, the dynamics of the relative density of urine according to Zimnitsky, the value of glomerular filtration, the concentration of nitrogenous wastes and the content of electrolytes in the blood. These studies are carried out depending on the severity of chronic renal failure monthly or every 2-3 months.