Transcript 8. Glomerulonephritis, pyelonephritis

The main symptoms
and syndromes in
kidney diseases.
Symptomatolgy of
acute and chronic
glomerulonephritis
and pyelonephritis.
renal function
 cleansing - excretion of metabolic
products, salts, dyes, chemicals
 Homeostatic - maintaining a constant
internal environment by regulating the
blood, osmotic pressure, KLR
 erytropoetychna
 vnutrishnosekretorna
 regulation of blood pressure
creening methods in
nephrology (the first
stage of the survey)
 blood test
 urinalysis
 with suspected renal dysfunction - the
content of creatinine in the blood
the second phase of the
survey
 clarifying the main syndrome installation
nosology, determining the degree of
activity of the process, clarification of
kidney function.
laboratory methods
 Microscopic methods of quantitative
urine,
 biochemical methods of blood and urine
 bacteriological,
 some (test for amyloid, search LE cells in
the blood)
 immune methods (CIC, antinuclear
antibodies, antibodies to DNA)
Instrumental methods
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ultrasound
radiological
radionuclide
kidney biopsy.
Urinalysis
 color (from straw yellow to amber-yellow)
 transparency (clear, after settling may
become turbid)
 reaction (pH 5.5-6.5)
 proportion (morning urine ranges from
1015 to 1025). Proteinuria 4 g / l
increases the proportion of 0.001 and 10
g / l glucose - 0,004.
Bacteriological
examination of urine
 microbial count (the number of bacteria in 1 ml
of urine) (low to 20 thousand, the critical 20100 thousand, truth more than 100 thousand)
 sensitivity to antibiotics and chemotherapy
 special bacteriological tests (detection of Lforms of bacteria, mycoplasma, fungi)
 for the diagnosis of tuberculosis of the kidneys
(urine for 12 h in enriched environment or
biological sample)
Evaluation ability of the
kidneys to urine dilution
and concentration
 proportion morning urine (not below 1018-1022)
 test on Zimnitskiy (urine collected during the day
in 3 hours 8 times. determine in each serving
size, proportion, ratio of night to day diuresis)
 sample of deprivation for 12 hours (from 19.00 to
07.00). If the proportion rises to 1024 and more
concentration of kidney function considered
satisfactory
 Score azotovydilnoyi function - serum
creatinine and urea in serum
 involved in renal electrolyte metabolism
as an indicator of kidney function (Na, K,
Ca, Mg, Cl).
X-ray of the kidneys.
 Survey urography - to determine the size and
shape of the kidney, the presence of
concretions.
 Urotomohrafiy - gives a three-dimensional
image of kidney
 Excretory urography - helps to determine not
only morphological but also functional status
of the kidneys and urinary tract.
 Infusional urography
 Retrograde (ascending pyelography) - reveals
asymmetry Wire cup-pelvic, strain the
kidneys.
 Renal angiography
 CT
Methods of radionuclide
study
 isotope renografiy - to determine
vascularization, activity of proximal
tubules and evacuation capacity of each
kidney.
 Apply hipuran, it is nontoxic, quickly
moves from the blood to the kidneys and
urinary excretion. Kidneys excrete about
80% due to its secretion in the proximal
tubule, and only 20% - by KF.
Normal renohrama
 Phase 1 - vascular (blood)
duration of 20-60 seconds.
 Phase 2 - secretory
(tubular) 2-3 min after
injection Contrast agents to
5 min.
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Phase 3 - excretory falling curve (expressing
Contrast excretion of
substances from the kidney.
Duration curve is steep fall
in 5 min., A plateau from 5
to 8 minutes.
Scanning kidney
 visual kidney using radionuclides
(neohidrynu) indicates localization, shape
and size of the kidneys, the degree of
local functional activity of the
parenchyma, focal and diffuse lesions,
abnormalities. Lets differentiate renal
tumors, abdominal and extraperitoneal
space.
thermography
 registration of spontaneous infrared
radiation of human skin.
Diffuse glomerulonephritis
 inflammatory infectious and allergic
disease with predominant and primary
involvement in the pathological process
of glomerular apparatus of the nephron
Classifications of
glomerulonephritis
(L.A. Pyrig)
 acute diffuse glomerulonephritis
 urinary syndrome
 nephrotic syndrome (mainly hematurinary,
hypertensive, edematous component)
 subacute (malignant) glomerulonephritis
 quickly progressing glomerulonephritis
chronic glomerulonephritis
type
 primary chronic
 secondary chronic
syndrome
 urinary
 nephrotic
stage
 anhipertenzive
 hypertensive
 chronic renal failure
phase
 aggravation
 remission
Acute glomerulonephritis
 infectious-allergic disease, mainly
affecting vascular renal glomeruli with
available also changes in the tubules and
interstitial tissue
Clinical
course options
rapid onset, severity of symptoms.
mono asymptomatic - gradual onset,
uclearness of symptoms.
Syndromes
 bladder - the presence of protein in the urine
(proteinuria to 3.5 g per day) formal blood
elements (red blood cells), cylinders
 nephrotic - proteinuria greater than 3.5 g per
day, hypoproteinemia, dysproteinemia,
hyperlipidemia, edema
Facies nephritica
 pale skin, swelling of the face and
eyelids, puffiness under the eyes.
Chronic diffuse
glomerulonephritis
 inflammation in the glomerulus, tubular
epithelial degeneration and progressive
proliferation of connective tissue, which
leads to the development of secondary
wrinkled kidney.
Principles of treatment
 considering clinical variant phase, stage of the
disease.
 diet number 7 (restriction of salt to 4-5 g, nephrotic
version - salt-free diet.
 medications
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pathogenetic therapy: corticosteroids, cytotoxic agents,
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aminoquinoline drugs
antihypertensive therapy in the presence of hypertension:
beta-blockers, clonidine
diuretics edema syndrome: furosemide, urehit, hypothiazide
anticoagulants and antiplatelet: heparin, fraksyparyn,
Courant, tyklid, clopidogrel
antibiotics in infectious complications
Pyelonephritis
 Nonspecific infectious inflammatory
process, which is localized in mostly at
cup-pelvic kidney and its tubulointerstitial area.
Chronic pyelonephritis
(CPN)
 Running across a sluggish, periodically
exacerbated bacterial inflammation of
renal parenchyma (cup-pelvic and renal
tubules with subsequent damage
glomeruli and renal vessels)
Etiology of CPN
 Saprophytes and pathogenic flora
(Escherichia coli, Enterococci,
Streptococcus, Proteus, Pseudomonas
aeruginosa)
 mycoplasma
 viruses (Coxsackie, adenovirus)
 fungi (Candida)
Pathogenesis of CPN
 microbial factor
 violation of the passage of urine
(mechanical and functional abnormalities
of the urinary tract)
 neurogenic bladder disorder
 state of nonspecific immune reactivity
 state of cellular and humoral immunity:
T-immunity level of Ig A, Ig G
Ways of infection in CPN
 ascending urynohennous
 hematogenous
 lymphogenous
Classification
localization
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one-sided
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two-sided
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pyelonephritis single kidney
phase of the disease
 aggravation
 partial remission
 complete remission
Major syndromes and
complications
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hypertension
CRF (renal failure)
paranefryt
hydronephrosis
uroseptic
dystrophy
anemia
Examples of formulations
diagnosis
 Secondary bilateral chronic
pyelonephritis, recurrent course, acute
phase. Secondary symptomatic
hypertension. CRF 1 stage.
 Left secondary chronic pyelonephritis,
latent, non-remission phase.
Nephrolithiasis, stones of left kidney.
CRF 0 stage.
Clinic CPN
 Pain (aching pain, positive
Pasternatskys’ s-m)
 syndrome of endogenous intoxication
(subfebrile, weakness headache, fatigue)
 bladder syndrome (nocturia, dysuria,
polakiuriya, pyuria, bacteriuria)
Laboratory studies in CPN
 low proteinuria (up to 1 g / l)
 leukocyturia
 bacteriuria
Instrumental studies in
CPN
 asymmetry curves with radioisotope
study
 according to ultrasound and radiography
lesions cup-pelvic
Diagnosis of CPN
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A history
clinical examination data
typical changes of urinary sediment
availability dizuricheskie phenomenon
combination of dysuria and urinary
signs of fever
 identify predisposing factors and
diseases
Treatment of chronic renal
failure (principles of
pathogenetic therapy)
Stages of treatment
 treatment of acute
 maintenance therapy (Antirecurrent
treatment)
Recovery passage of urine (neurogenic,
Dysfunctional or urological)
anti-inflammatory therapy (antibiotics)
Antibiotics
fluoroquinolones
 zanotsyn (ofloxacin) - blocks the bacterial enzyme
DNA hidratazu, damages the cell membrane of
bacteria is well into the fabric of the urinary system
macrolides
 Wilprafen (josamycin) 0.5 2 times (12-14 days)
 flurenisid (ie 0, 05 and 0.15, capsules 0.3, candle
0.1) destroys chlamydia, corrects immunity.
 uroseptics group Nitroxoline (5-NOC) to
0.1 to 4 times a day or nalidixic acid
(negram, nevihramon) by 0.5-1.0 4
times
 correction of microcirculation and blood
flow in the kidney (aminophylline,
pentoxifylline, stugeron, heparin,
fraksyparyn)
 effect on free radicals - antioxidants:
unitiol, halaskorbin, emoksypin,
Essenciale, vitamin E, tiotriazolin.
 immunocorrection (prohydiozan,
pirogenal. pentoxyl, methyluracil,
echinacea)
 correction syndrome EI
 enzyme: vobenzim (3-9 table. 3 times),
flohenzym (2-4 table. 3 times)
Pharmaceutical
preparations of plant
material
Hofitol - artichoke leaves drug (2% solution
for injection)
 diuretic, zhovchehinnyy, detoxification,
solerozchynnyy impact
 shows: Diabetic nephropathy and
dismetabolic, chronic renal failure
lespenefryl (lespyflan) - a drug with stems
and leaves lespedezy capitate (3-6
spatulas of tea a day for 15 minutes
before eating, drinking a small amount of
water)
accelerates the excretion of nitrogenous
substances in the urine
 indications: chronic renal failure
Canephron - contains lovage, rosemary,
centaury, hips. (due to the able 3-4 times a
day)
 anti-inflammatory, antiseptic, diuretic,
antihypertensive effect
 indications: chronic pyelonephritis, urate
nephrolithiasis, chronic renal failure
Chronic renal failure (CRF)
 This is a consequence of many chronic renal
diseases, gradual and steady deterioration of
glomerular and tubular kidney function such an
extent that the kidneys can not maintain the normal
composition of the internal environment.
 The main property CRF - exhaustive compensatory
abilities kidney impossibility (as opposed to acute
renal failure) regeneration of the parenchyma.
Etiology and pathogenesis
of chronic renal failure
 Chronic glomerulonephritis, subacute, progressive
GN
 CRF
 Collagen (SLE, scleroderma, polyarteritis nodosa)
 metabolic diseases (diabetes, gout, amyloidosis)
 congenital kidney disease (polycystic, kidney
hypoplasia syndrome, Fanconi syndrome, Alporta
 primary vascular lesions (renal artery
stenosis, malignant hypertension,
essential hypertension)
 obstructive nephropathy (urolithiasis,
hydronephrosis, tumors of the urinary
system)
Major disturbances of
homeostasis in CRF
 excretion of nitrogenous toxins (urea,
creatinine, uric acid)
 support water and electrolyte balance
(urine output less than 600 ml per day)
Classification CRF
S.I.Ryabova (1976)
 latent (creatinine level in serum below
0.18 mmol / l, Cp above 50% of
predicted)
 azotemic (cock kraetyninu from 0.19 to
0.71 mmol / l KF 50-10% of predicted)
 uremic (content creatinine 0.72 mmol / l
and above, cf 10% and below)
 Each stage is divided into A and B
Classification of chronic
renal failure by Ratner
 I - increase in plasma creatinine 0,170,44 mmol / l
 II - 0,45-0,88 mmol / l
 III - 0,89-1,32 mmol / l
 IV - 1,32 and above
Clinic CRF (initial period)
 fatigue, drowsiness, lethargy, loss of
appetite
 polyuria, nocturia
 myazeva weakness, twitching
 osteomalacia, osteoporosis, bone pain
 itching, paresthesia, epistaxis,
subcutaneous hemorrhage
 "Uremic gout", nausea, vomiting,
diarrhea
Clinic CRF (expanded
period)
 pale yellow complexion, dry skin,
soluable, tongue dry, brown, mouth odor
of ammonia
 hypertension, retinopathy, cardiac
asthma, gallop rhythm, congestive heart
failure
Clinic of CRF (end stage)
 pericarditis with retrosternal pain,
dyspnea, pericardial friction noise ("toll")
 twitching, encephalopathy, uremic coma
with acidotic breathing
 anemia, leukocytosis, thrombocytopenia
 impotence, amenorrhea, gynecomastia
(due to delays prolactin)
Laboratory diagnosis of
CRF
 serum creatinine and blood urea
 relative density of urine
 glomerular filtration and tubular
reabsorption
Treatment of chronic renal
failure (task)
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maintenance of homeostasis
slowing progression
treatment of complications of uremia
KF at 35 to 10 ml / min treatment with
conservative methods
 with more severe disorders - software
hemodialysis, kidney transplant
Conservative treatment of
chronic renal failure
 diet (table 7a, 20-25 grams of protein a
day, 7b, 40 - g protein per day)
 adequate fluid intake
 control input electrolytes - sodium and
potassium, with hiperpotassemia - 20-30
ml of 10% calcium gluconate or 200 ml of
5% sodium bicarbonate, 5% glucose with
insulin
 reduce delays end products of protein
metabolism (sorbents, siphon enema,
laxatives - sorbitol, xylitol)
 antihypertensive therapy - dopehit,
hemiton (Clonidine) - do not reduce renal
blood flow.
 treatment of anemia
 treatment of uremic osteodystrophy
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correction of acidosis
treatment of infectious complications
med. physsical culture
treatment of the underlying disease that
led to uremia
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