Acute paranephritis

Acute paranephritis (from the Greek. Rara - near, past, beyond and nephritis, from nephros - kidney) - acute purulent inflammation of the perirenal adipose tissue. It is caused by the same microorganisms as kidney abscess, but most often it is found by Escherichia coli, spreading in the ascending way, less often - Staphylococcus spp., Spreading hematogenously.

[1], [2]

Risk factors

Risk factors for paranephritis include urinary stasis, urinary obstruction, urolithiasis, neurogenic bladder dysfunction, and diabetes mellitus. Currently, due to the widespread use of antibiotics, para-ephritis occurs much less frequently.

[3], [4], [5], [6], [7]

Symptoms of the acute paranephritis

Symptoms of acute paranephritis in the initial stage of the disease have no characteristic symptoms and begin as any acute inflammatory process with a rise in body temperature to 39–40 ° C, chills, and indisposition.

Local symptoms of acute paranephritis are initially absent. In this period, acute paranephritis is often mistaken for an infectious disease. After 3-4 days, and sometimes later, local symptoms appear in the form of pain in the lumbar region of varying intensity, pain on palpation in the osteo-vertebral angle from the corresponding side, a protective contraction of the lumbar muscles, pain on tapping in this area.

Sometimes in the lumbar region on the affected side there is hyperemia and swelling of the skin. Somewhat later, the spinal curvature to the affected side is revealed due to the protective contraction of the lumbar muscles, the patient's characteristic position in bed with the leg to the abdomen and sharp pain when it is straightened (the so-called psoas-symptom, or the “stuck heel” symptom). To recognize acute paranephritis at the onset of the disease is not easy, as local phenomena are mild or the clinical picture is masked by the manifestation of the disease, a complication of which is paranephritis. Often the course of the disease resembles an infectious or purulent disease with an unclear localization of the focus. And it is not by chance that such patients are often hospitalized to infectious and therapeutic departments, much less often to surgical and urological ones.

Symptoms of acute paranephritis are largely dependent on the localization of the purulent process. With anterior paranephritis during palpation of the abdomen in the region of the corresponding hypochondrium, soreness often occurs. In some cases, tension in the muscles of the abdominal wall is present. Sometimes in the region of hypochondrium or somewhat lower, it is possible to feel a dense, painful, immobile tumor-like inflammatory infiltrate.

In upper acute paranephritis, symptoms of the pleura and pain in the shoulder on the affected side are often noted, limiting the mobility of the diaphragm dome. At the same time, it is possible to move the kidney downwards, so it becomes available for palpation.

For the lower acute paranephritis is characterized by a low location of the inflammatory infiltrate palpable through the abdominal wall, as well as pronounced psoas-symptom.

[8], [9], [10]

Forms

According to the mechanism of occurrence distinguish primary and secondary para-ephritis. In primary paranephritis, the disease of the kidney itself is absent. Microorganisms get into the peri-renal cellulose by hematogenous from other foci of inflammation (furuncle, osteomyelitis, follicular angina). Most often this happens due to immunodeficiency, hypothermia or overheating of the body. Perinephritis can also occur after injury to the lumbar region or due to surgery on the kidney. In some cases inflammation of the adjacent organs leads to paranephritis - the uterus, ovaries, rectum, appendix.

Secondary paranephritis is usually a complication of purulent-inflammatory process in the kidney itself (abscess, kidney carbuncle, pyonephrosis). At the same time, the inflammatory process of the renal parenchyma extends to the perrenal fatty tissue.

Depending on the localization of the purulent-inflammatory process in perirenal cellulose, there are upper, lower, anterior, posterior, and total perinephritis. In the upper paranephritis, the purulent process is in the region of the upper segment of the kidney, in the lower region, in the lower segment, in the anterior segment, on the anterior surface of the kidney, in the posterior region, in the entire paranephritis, all departments of the perirenal tissue are involved in the inflammatory process. Although extremely rare, there are cases of bilateral paranephritis. According to the clinical course, paranephritis can be acute and chronic.

Acute paranephritis first passes through a stage of exudative inflammation, which may be reversed or pass into a purulent stage. If the purulent process in the perirenal fiber tends to spread, then interfascial separations usually melt, and, having reached a large size, the pus can spread outside the cellulose, forming extensive purulent streaks (it can descend down the ureter, in the iliac muscle to the pelvis). Perhaps the formation of phlegmon retroperitoneal space. Cellulitis can break into the intestine, abdominal or pleural cavity, into the bladder or under the skin of the inguinal area, through the locking hole to spread to the inner surface of the thigh. Upper acute paranephritis is complicated by subphrenic abscess with pus in the pleura. And sometimes in the lung. In exceptional cases, an abscess breaks out into the lumbar region. Differential diagnosis should be carried out with acute appendicitis, abscess subphrenic space, pneumonia.

[11], [12]

Diagnostics of the acute paranephritis

Convincing confirmation of purulent acute paranephritis and pus during puncture of the kidney tissue. However, a negative result of the study does not exclude purulent inflammation.

On the radiographs of the lumbar region, it is not uncommon to find a curvature in the lumbar spine towards the lesion, a distinct smoothing or absence of the edge of the lumbar muscle contour from this side. The contours of the kidney, depending on the size and distribution of the infiltrate, are normal in some cases, smoothed and even absent in others. It is also possible high standing and immobility of the diaphragm, effusion in the pleural sinus from the patient side.

On the excretory urogram, it is possible to reveal the deformation of the pelvis and cups due to compression of the latter by inflammatory infiltrate. The upper part of the ureter is often biased in a healthy way. In the pictures taken on inhalation and exhalation, the picture of the contours of the pelvis and cups is the same on the sore side and blurred or doubled on the healthy side. This indicates immobility or a sharp restriction of the mobility of the affected kidney. Valuable information in case of purulent acute paranephritis can be provided by CT, ultrasound and radioisotope research methods. In some patients, diagnostic puncture of the perinephric infiltrate is resorted to.

In severe septic patients, true albuminuria is possible, as well as the presence of cylinders in the urine (as a result of toxic nephritis).

[13], [14]

Differential diagnosis

Differential diagnosis of acute paranephritis is performed with many diseases, primarily with hydronephrosis, acute pyelonephritis, and kidney tuberculosis. A history of chronic inflammation in the kidney, pyuria, bacteriuria, active leukocytes in the urine, deformation of the pyelocaliceral system, characteristic of pyelonephritis, the identification of other kidney diseases with an appropriate clinical picture is in favor of paranephritis. It should be borne in mind the need to differentiate acute paranephritis from neoplasm of the kidney.

[15], [16]

Treatment of the acute paranephritis

Treatment of acute paranephritis is the appointment of broad-spectrum antibiotics, their combination with sulfanilamide drugs and uroanteptics. Detoxification and fortifying treatment is obligatory - glucose infusion, saline and colloidal solutions, vitamins, heart remedies are prescribed, according to indications blood transfusions are performed. The use of antibacterial therapy and active therapeutic measures in the early stage of acute paranephritis in a number of patients allows to reverse the development of the inflammatory process, which leads to recovery without surgical intervention.

When an abscess is formed or if the conservative treatment fails for 4-5 days, when the clinical symptoms increase, surgical treatment is indicated - revision of the retroperitoneal space, opening of the abscess and drainage of the periorenal space. Oblique lumbar incision expose the retroperitoneal space and reveal a purulent focus. When the latter is located at the upper segment or along the front surface of the kidney, it is not always easy to find it. After opening the main purulent focus, they stupidly destroy the fascial bridges, among which small abscesses can be located. After opening the purulent focus it must be well drained. The back angle of the wound should be left unstitched.

In acute paranephritis of renal origin (pyonephrosis, apostematozny unshaven, kidney carbuncle), if there is an indication for nephrectomy, and the condition of patients is severe, it is advisable to perform the operation in two stages: first - opening the abscess and draining the retroperitoneal space, second - nephrectomy after 2-3 weeks taking into account the patient's condition. Treatment of acute paranephritis with antibiotics, as well as general strengthening therapy, should be continued for a long time until the patient's condition stabilizes.

Forecast

Acute paranephritis usually has a favorable prognosis. In the secondary form of the disease, since it is a complication of one of the isurological diseases, the prognosis depends on the nature of the latter.