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Chronic pyelonephritis in children
Last reviewed: 17.10.2021
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Chronic pyelonephritis in children is a chronic destructive microbial-inflammatory process in tubulointerstitial tissue of the kidneys. Chronic pyelonephritis has a recurrent or latent course.
Distinguish chronic primary non-obstructive pyelonephritis and chronic secondary obstructive pyelonephritis.
Chronic primary non-obstructive pyelonephritis is a microbial-inflammatory process in the renal parenchyma, when using modern research methods it is not possible to identify factors and conditions that contribute to the fixation of microorganisms and the development of inflammation in the tubulointerstitial tissue of the kidneys.
Chronic secondary obstructive pyelonephritis is a microbial inflammatory process in the kidney tissue that develops against the background of developmental anomalies, dysembryogenesis of the renal tissue, metabolic disorders (oxaluria, uraturia, phosphaturia, neurogenic bladder dysfunction, functional disorders of urodynamics).
In the genesis of primary chronic pyelonephritis a certain role is played by hereditary factors - antigens HLA-A, and B17 and often antigenic combinations A1B5; A1B7; A1B17 (with the greatest risk of developing the latter two).
[Symptoms of chronic pyelonephritis in children
During the exacerbation, temperature rises, complaints of pain in the lower back, abdomen, to some extent expressed symptoms of intoxication, dysuric symptoms, urinary syndrome, increased ESR, neutrophilia. During the period of remission fatigability, pallor of the skin, "blue" under the eyes, asthenia - symptoms of chronic intoxication.
With latent flow of chronic pyelonephritis, there are no clinical manifestations. Changes in the urine of a pathological nature are detected during preventive examinations, during a survey to visit the pool, before vaccination, etc. Sometimes attentive parents and doctors who observe the child for several years can mark traces of chronic intoxication.
As chronic pyelonephritis develops, the patients notice a gradual change in the functions of the medulla of the kidney, and the effectiveness of osmotic concentration of urine decreases. A very important diagnostic criterion is a violation of the concentration ability of the kidneys. It is important to determine the relative density of urine.
It is necessary to test with dryness. Sample with dryness - 18-hour. From 14 o'clock in the afternoon the patient is offered nothing to drink. In the evening you can eat cookies, crackers, even fried potatoes. At 8 o'clock in the morning the urine is collected. After the patient drinks as much as he wants. With such a sample, the relative density of urine should not be less than 1,020. If it is lower, this indicates a violation of the concentration ability of the kidneys.
With chronic pyelonephritis on the roentgenogram are determined: the asymmetry of the magnitude of both kidneys; deformation of the renal system; uneven release of contrast medium; a decrease in the thickness of the kidney parenchyma as compared with the contralateral; significant fluctuations in the thickness of the parenchyma in the same kidney at different sites.
One of the earliest manifestations of the sclerotic process is the flattening and shrinking of the papillae, the elongation and extension of the cups, their pulling to the periphery of the kidneys, and the rounding of the angle occurs at the base of the cups. The ratio of the calyceal system and the parenchyma of the kidney is represented by the renal-cortical index - the ratio of the area of the calyceal system to the area of the kidney itself. By its magnitude, it is possible to detect a disproportion between the wrinkled parenchyma of the kidney and the expanding cup-and-pelvic system. The renal cortical index is normal at 60-62%, the figures below indicate chronic pyelonephritis and shrinkage of the kidney. In children with chronic pyelonephritis, the rate of kidney growth slows down, which is why it is important to conduct an X-ray study in dynamics.
Radioisotope renography allows one-sided violations of secretion and excretion, reduction of renal blood flow. Dynamic nephroscintigraphy provides information on the state of the functioning renal parenchyma.
Dynamic computer u-scintigraphy allows for chronic pyelonephritis to determine not only the side of the lesion, but also the degree of disturbance of vascularization of the kidney, the secretory activity of the tubular epithelium, and urodynamics.
The combination of two-dimensional ultrasound and Doppler studies makes it possible to assess the condition of not only the kidney parenchyma, but also the blood flow; assess peripheral renal vascular resistance. As the process develops in chronic pyelonephritis arterial hypertension appears.
Due to chronic immune damage, the pathological process in the kidneys progresses steadily, although remissions are possible. With latent flow of chronic pyelonephritis, the urinary syndrome is not stable, there may be a norm, in such cases there may be "asymptomatic" bacteriuria. It should also be taken into account the fact that renal dysfunction may persist even during remission, if they are caused by evolving nephrosclerosis. Therefore, the sign of exacerbation of chronic pyelonephritis is not the presence of functional disorders, but their growth.
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Treatment of chronic pyelonephritis in children
The regime provides for sufficient sleep, walking outdoors, hygiene measures. Diet with exacerbation (7-10 days) is used milk-vegetable with a moderate restriction of protein (1.5-2, g / kg body weight), salt (up to 2-3 grams per day). It is recommended to drink enough - 50% more than the norm in the form of weak tea, compotes, juices. It is recommended to take slightly alkaline mineral waters such as Slavyanovskaya and Smirnovskaya at a rate of 2-3 ml / kg of body weight per reception for 20 days at 2 courses per year. Compliance with the regime of frequent urination (2-3 hours depending on the age).
Etiotropic therapy is prescribed taking into account the sowing of the pathogen, it is necessary to change preparations in connection with the development of resistance of the microflora, and after the symptoms of exacerbation abate, a maintenance therapy of 7-10 days of each month, prolonged up to 3-4 months, is prescribed. Patients with a high risk of progression should be prevented for several years.
The presence of vesicoureteral reflux requires an increase in the duration of treatment to 10-12 months. In chronic pyelonephritis, antioxidants, vitamins, drugs that increase the body's reactivity, improve kidney blood flow are prescribed.
In the period of persistent clinical and laboratory remission, hardening procedures are performed, LFK.
What prognosis does chronic pyelonephritis have in children?
Recovery is possible with primary chronic nephritis, with a secondary unfavorably increasing decrease in renal function, an increase in nephrosclerotic changes and hypertension, the development of chronic renal failure.