Neuritis ICD code 10. Acute tubulointerstitial nephritis. Clinical recommendations. Treatment outcome

Included: chronic:

• infectious interstitial nephritis
• pyelitis
• pyelonephritis

If it is necessary to identify the infectious agent, an additional code (B95-B98) is used.

Included:

• Interstitial nephritis NOS
• Pyelitis NOS
• Pyelonephritis NOS

Excludes: calculous pyelonephritis (N20.9)

Excluded:

• kidney and ureteral stones without hydronephrosis (N20.-)
• congenital obstructive changes of the renal pelvis and ureter (Q62.0-Q62.3)
• obstructive pyelonephritis (N11.1)

If it is necessary to identify a toxic substance, use an additional external cause code (Class XX).

In Russia, the International Classification of Diseases, 10th revision (ICD-10) has been adopted as a single normative document for recording morbidity, reasons for the population's visits to medical institutions of all departments, and causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

Processing and translation of changes © mkb-10.com

Etiology of acute pyelonephritis and current methods of treating the disease

Acute kidney pyelonephritis, according to statistics, is common, second only to upper respiratory tract infections.

Therefore, it is advisable to familiarize yourself in advance with the question of what acute pyelonephritis is. We will analyze the symptoms and treatment characteristic of this disease in detail - this will allow you to quickly respond if the disease occurs.

Acute pyelonephritis: etiology and pathogenesis

Primary inflammation, usually appearing after tonsillitis, skin furunculosis, mastitis and other infectious diseases.

Acute pyelonephritis in children and adults manifests itself in the form of the following symptoms:

• headache;
• general weakness. However, children, on the contrary, may experience strong general arousal;
• pain in the joints, as well as the muscles of the arms and legs;
• nausea, periodically accompanied by vomiting;
• Due to the production of large amounts of sweat, a small amount of urine is released. In general, no urination disorders are observed;
• chills are characteristic of such a form of the disease as acute purulent pyelonephritis;
• Often, simultaneously with chills, sweating occurs and the temperature rises. It either reaches 40 degrees, then drops to 37.5, forming the so-called hectic oscillations. Such fluctuations can occur several times in one day, signaling that new pustules have formed;
• dull pain in the lumbar region. These sensations tend to continue in the area under the ribs or in the groin. They occur approximately on the second or third day after the onset of the disease. But sometimes they appear later. If discomfort is observed on one side, it means that unilateral pyelonephritis has occurred. If it’s on both sides, then it’s double-sided. When moving your legs, coughing, or making careless turns, these sensations intensify;
• Children may be characterized by manifestations of irritation of the meningeal membranes. In other words, it becomes difficult for them to move their necks and fully extend their legs. It becomes difficult for the child to tolerate bright light, loud sounds, and strong smells. Sometimes touching is also annoying.

The following signs of acute pyelonephritis are characteristic of secondary inflammation:

• Colic in the kidney area occurs when urine encounters stones during outflow. This phenomenon is accompanied by a rise in temperature to 39 degrees and a general deterioration in health. Temperature changes especially sharply in children;
• the person experiences constant headaches;
• thirst often occurs;
• lumbar pain becomes permanent;
• there is a faster than usual heartbeat;
• Problems occur during urination.

Diagnostics

Differential diagnosis of acute pyelonephritis includes the following procedures:

• palpation of the area under the ribs and lower back. With this diagnosis, as a rule, the abdominal and lower back muscles are tense, and the kidney is enlarged. The contact of the edge of the palm with the 12th rib when tapping leads to painful sensations. The doctor must exclude the possibility of the patient suffering from appendicitis, pancreatitis, acute cholecystitis, typhus, sepsis, meningitis, ulcers;
• urological examination. Men need to be examined rectally, women – vaginally;
• general urinalysis - necessary to determine the content of bacteria and leukocytes, red blood cells, and protein. This approach helps to determine whether a stone is interfering with the flow of urine, and also to determine whether the patient has pyelonephritis one-sided or two-sided. Destructions in the tissues of the kidneys and ureter are determined by red blood cells;
• urine culture - helps determine the type of bacteria, as well as the degree of their sensitivity to certain antibiotics. This research method is considered almost ideal for the purposes listed;
• biochemical examination of urine - reveals an increase in the amount of creatinine and a decrease in potassium and urea. This picture is just typical for acute pyelonephritis;
• Zimnitsky's test - helps to determine the amount of urine per day. In a sick person, the volume of urine at night will exceed the volume of urine during the day;
• biochemical blood test - if the content of creatinine and urea increases, which is typical for this disease, the analysis will be able to record it;
• Ultrasound allows you to quickly and accurately diagnose an increase in the size of the kidney and a change in its shape. The presence of kidney stones also becomes apparent. Their location is also determined with high accuracy.

Acute pyelonephritis itself is coded according to ICD-10 N10-N11.

If the disease is confirmed, it is necessary to undergo hospitalization - this will help more accurately determine the form of the disease and its stage.

Treatment

Once the diagnosis is confirmed, the patient is prescribed bed rest. Its duration depends on many factors - the presence or absence of complications, intoxication.

It is undesirable for patients to even get out of bed again. Physical activity of varying degrees of intensity is out of the question.

Moreover, in case of exacerbation, it is advisable to undergo treatment in a hospital setting under the round-the-clock supervision of specialists. As soon as complications are removed, exacerbation decreases, blood pressure normalizes, and the regimen becomes less strict.

The next mandatory requirement for a speedy recovery is a strict diet for acute pyelonephritis. Spicy seasonings, fried foods, canned food, and alcoholic beverages in any dosage are strictly prohibited. Even such healthy food as broth can be harmful if it is rich. All of the foods listed can irritate the organs involved in the secretion of urine.

But what you can, and even need to do, is drink at least two or two and a half liters of water every day.

If possible, you can increase the volume to three liters. This helps relieve intoxication.

Since liquid is not retained in the body, you don’t have to worry that large amounts of water will cause harm.

However, when there is an exacerbation of chronic pyelonephritis, treatment with water must be slowed down. It is advisable to reduce the volume of fluid consumed so that it is equal to the volume excreted per day.

However, it is not at all necessary to consume exclusively water. It can be replaced with fresh natural juices, green tea, compote, rosehip decoction, cranberry juice, jelly, green tea, mineral water. Just like water, there must be a sufficient amount of salt in the body of a patient with pyelonephritis.

It is advisable to include in your diet a large amount of fermented milk foods and foods that are rich in carbohydrates, fats, proteins, and vitamins.

The total caloric content of meals should be no more than kcal - this means the daily diet of an adult patient.

Fruits, vegetables, and cereals are also welcome. Meat is also desirable, but only if it is served boiled and without hot spices.

In case of primary disease, treatment of acute pyelonephritis with broad-spectrum antibiotics is prescribed. But after the specialist determines the sensitivity, he can prescribe targeted drugs.

The most commonly prescribed antibiotics are Cefuroxime, Gentamicin, Cefaclor, Ciprofloxacin, Norfloxacin, Ofloxacin, Cefixime. However, if the disease is severe and treatment does not bring tangible results, the doctor may prescribe other medications. Or prescribe a combination of them - everything is very individual.

Antibacterial drugs are prescribed depending on whether the causative agent of pyelonephritis is sensitive to them or not. However, in any case, antibiotics for acute pyelonephritis should not be taken for more than six weeks - otherwise the disease may become chronic or, if improvements begin to appear, a relapse will occur. It is recommended to change the medication on average every five to seven days.

As for anti-inflammatory drugs, Furagin, Urosulfan, Biseptol, Gramurin, Furadonin, Nevigramon are most often recommended.

If the ureter is blocked by a small stone, you can wait for it to pass on its own.

Catheterization is an excellent help in this case. If drug therapy and catheterization do not help for three days, surgical intervention cannot be ruled out to remove the stone. If the formation is large, intervention is carried out immediately.

Next, artificial removal of the fluid is carried out - drainage. In parallel with this, the doctor prescribes therapy, which consists of taking antibacterial agents. Thanks to it, chills and elevated body temperature are relieved, and pain is relieved.

With such a serious disease as acute pyelonephritis, treatment must be carried out under the supervision of a specialist; self-medication is unacceptable.

Video on the topic

Even more useful information about chronic acute pyelonephritis - causes, etiology and methods of treating the disease - in the TV show “Live Healthy!” with Elena Malysheva:

Acute and chronic pyelonephritis are not the most pleasant diseases, but they are curable. If you start proper treatment in time under the supervision of specialists, you can prevent complications of acute pyelonephritis and get rid of the disease. The prognosis in such a case is almost always favorable.

Pyelonephritis - ICD code 10

A disease caused by the penetration of pathogenic microflora into the renal pelvis is called pyelonephritis. It is one of the most common nephritic disorders. Pyelonephritis according to the ICD is coded N10 and N11, if we are talking about the acute form. The disease is dangerous because it can easily develop into a chronic disease or an already purulent inflammation will join, which can endanger the patient’s life.

Acute pyelonephritis ICD 10

Work experience 18 years.

The causative agents of nephritic disease include various bacteria, primarily coccal and proteus. Infection can be either ascending (urogenic), that is, ascending through the urinary tract, or descending (hematogenous), that is, the infection is carried through the bloodstream. There is no risk group as such; children, adolescents, adults and the elderly suffer from pyelonephritis. However, the more genitourinary system disorders a person has, the higher the chances of this disease occurring. Most often, infection of the renal pelvis occurs with nephroptosis and dystopia.

Acute pyelonephritis (ICD 10 code - N10) has rather poorly expressed symptoms:

• body temperature above 38 degrees;
• severe pain in the lumbar region, affecting the muscle mass of the back;
• headache that practically does not go away, including under the influence of painkillers;
• weakness, lethargy, drowsiness;
• depressed mental state, depression;
• lack of appetite;
• increased diuresis, or simply frequent urination;
• cloudiness in the urine, a pronounced nonspecific unpleasant odor from it.

Not only many other urogenital diseases, but also acute respiratory viral infections have similar symptoms, which significantly complicate diagnosis. The diagnosis is made only based on the results of laboratory tests of blood and urine, as well as on the basis of the results of ultrasound and radiography. When pyelonephritis is confirmed (ICD code N10), additional studies are carried out to identify the pathogen (codes B95-B97). This action must be done to prescribe “targeted” antibacterial drugs, since antibacterial therapy is strictly necessary, and the use of broad-spectrum antibiotics in this case will not justify itself and there will be a risk of developing a so-called superinfection, that is, the pathogen will mutate and will be immune to most drugs, which will require long-term therapy, and the patient becomes much “heavier.” My patients use a proven remedy, thanks to which they can get rid of urological problems in 2 weeks without much effort.

Treatment of pyelonephritis (ICD code 10 N10) is carried out only in a hospital setting, therapy takes from three weeks (primary, without complications, timely start of treatment) to three or even four months (relapse, with complications). It includes:

• antibacterial therapy to combat the pathogen;
• uroseptic drugs;
• immunocorrective agents in combination with vitamins;
• detoxification medications, primarily IVs with polyionic solutions and diuretics;
• hemodialysis and plasmaphoresis are possible if the patient’s condition worsens;
• NSAIDs for relieving exacerbations;
• gentle diet;
• some folk remedies, primarily herbal and berry infusions.

Despite the fact that the acute form of the disease is quite difficult to tolerate, especially in the first days, the prognosis is generally considered favorable, provided that all doctor’s prescriptions are strictly followed.

Pyelonephritis (ICD 10): causes, diagnosis, symptoms

Pyelonephritis is a kidney disease caused by pathogenic microorganisms that penetrate the kidneys and cause inflammation in the renal pelvis. In Russia, the International Classification of Diseases, 10th revision, is in force, which makes it possible to record morbidity, the causes of patient complaints and visits to medical institutions, as well as conduct statistical research. ICD 10 identifies pyelonephritis in chronic and acute forms. From this material you will learn the code for pyelonephritis according to ICD 10, the classification of forms of the disease in this system, as well as the symptoms, causes and methods of treating the pathology.

Acute pyelonephritis ICD 10

Acute tubulointerstitial nephritis is the full name of this pathology in the International Classification of Diseases, 10th revision. Acute pyelonephritis code according to ICD 10 is determined by number 10. This code also denotes acute infectious interstitial nephritis and acute pyelitis. When it is important to identify the pathogen in diagnosing a disease, doctors use codes B95-B98. This classification is used for similar agents that cause the disease: streptococci, staphylococci, bacteria, viruses and infections. The use of these codes is not mandatory in the primary coding of the disease.

Causes of pyelonephritis

Most often, pyelonephritis occurs during the off-season, when the body succumbs to various external factors, which become a trigger for the development of the disease. The disease itself is caused by pathogenic microorganisms, including:

The penetration of these bacteria into the cavity of the bladder, where they multiply and carry out their vital functions, occurs through the urethra. Often the causative agent of pyelonephritis is E. coli, which enters the body after defecation due to the close location of the anus and urethra. The provoking factor of the pathology may be a decrease in immunity due to:

• transmission of colds and viral diseases;
• observed infectious processes;
• hypothermia of the body;
• neglect of the rules of intimate hygiene;
• diabetes;
• problems with urine outflow: incomplete bowel movements, reverse outflow of urine;
• urolithiasis with complications.

People susceptible to diseases of the genitourinary system are at risk of developing pyelonephritis. People with congenital diseases of the kidneys, bladder and genital organs may also encounter this pathology. The likelihood of getting sick increases if you have undergone surgery, age-related changes, injuries, or have an active sex life.

Acute symptoms

In the acute course of pyelonephritis, symptoms appear almost immediately after the renal pelvis is damaged by pathogenic microorganisms. The disease can be recognized by the appearance of the following clinical picture:

1. Painful sensations in the kidney area during walking, physical activity and even at rest. The pain can be localized in one area, or it can spread throughout the entire lower back, being encircling in nature. When tapping in the area of ​​the kidneys, as well as palpating the abdomen, increased pain may be observed.
2. There is a deterioration in health, increased fatigue, general weakness and malaise.
3. Lack of appetite, nausea and vomiting.
4. Increased body temperature, accompanied by chills, which may last for a week.
5. Increased urination and cloudy urine.
6. Swelling of the eyelids and limbs.
7. Paleness of the skin.

These symptoms appear in almost every case of pyelonephritis. There is also a list of symptoms that are not characteristic of this disease, but indicate it:

1. Toxic poisoning resulting from the activity of bacteria. Manifested by fever and a strong increase in temperature (up to 41°C).
2. Increased heart rate, accompanied by pain.
3. Dehydration of the body.

Ignoring such symptoms can lead to a complicated course of pyelonephritis and the transition of the acute form to the chronic form.

Chronic pyelonephritis ICD 10

The full name of this disease according to the International Classification of Diseases is designated as chronic tubulointerstitial nephritis. Chronic pyelonephritis according to ICD 10 is identified by number 11. Code number 11 also includes chronic forms of diseases such as infectious interstitial nephritis and pyelitis. In a narrower classification of chronic pyelonephritis, ICD 10 is further divided into several points. Number 11.0 denotes non-obstructive chronic pyelonephritis, that is, one in which the outflow of urine occurs as usual. Number 11.1 indicates obstructive chronic pyelonephritis, in which the function of the urinary system is impaired. If necessary, the documentation indicates not only the ICD 10 code denoting chronic pyelonephritis, but also the causative agent of the disease using codes B95-B98.

Symptoms of the chronic form

The chronic form of the disease in a quarter of cases is a continuation of the acute form of pyelonephritis. Due to the structural features of the female genitourinary system, women are more susceptible to developing this disease. Chronic pyelonephritis most often occurs in a latent form, so the symptomatic manifestations are very mild:

1. Lower back pain usually does not occur. A weakly positive Pasternatsky Symptom is observed (painful sensations when the lower back is tapped).
2. There is no disturbance in the outflow of urine, but the amount of urine produced increases and its composition changes.
3. There are headaches, weakness, and increased fatigue.
4. There is an increase in blood pressure.
5. Hemoglobin decreases.

Chronic pyelonephritis can worsen several times a year during the off-season or due to other diseases. During exacerbation, the chronic form is similar in symptoms to the acute form.

Diagnostics

When the first symptoms of the disease occur, you must consult a urologist, who will listen to the patient’s complaints and prescribe a series of tests to confirm the diagnosis. The following instrumental and laboratory research methods will help identify pyelonephritis:

1. Ultrasound of the kidneys. The disease is characterized by the occurrence of stones, changes in the density and size of the organ.
2. Computed tomography of the kidneys. It will help determine the condition of the organ and the renal pelvis, as well as eliminate the possibility of urolithiasis and abnormalities in the structure of the kidneys.
3. Excretory urography indicates limited mobility of diseased kidneys, the presence of deformation of the renal pelvis or a change in contour.
4. Survey urography will help determine the increase in the size of the organ.
5. Radioisotope renography will assess the functional capacity of the kidneys.
6. General blood analysis. The test results will show an increase in the level of white blood cells with a simultaneous decrease in the level of red blood cells.
7. Blood chemistry. Indicates a decrease in albumin, an increase in urea content in the blood plasma.
8. Analysis of urine. The presence of protein, an increase in the number of leukocytes and salt levels are observed.
9. Bacteriological culture of urine. Detects Escherichia coli, staphylococcus or other microorganisms that provoke pyelonephritis.

1. The Zimnitsky test allows you to analyze the organ’s ability to concentrate urine. Using the sample, doctors determine the amount and density of the material taken, and also compare the resulting sample with the daily rate of urine excreted in a healthy person.
2. The Nechiporenko test indicates an increase in the level of leukocytes and a decrease in the level of erythrocytes, the presence of bacteria, as well as simple and epithelial casts in the urine.

In chronic pyelonephritis, the readings may differ slightly from the test readings in the acute form of the disease: pathogenic microorganisms are not detected, and inflammatory processes are not detected. However, an experienced doctor, based on test results and manifestations of the disease, can always make the correct diagnosis and prescribe timely treatment.

Treatment

Only a specialist can prescribe drugs for the treatment of pyelonephritis. Self-medication can cause complications and difficulties in treating pyelonephritis in the future. Most often, doctors prescribe the following therapeutic methods:

1. Taking antibacterial drugs. Antibiotics are effective in eliminating microorganisms that are the main causative agent of pathology. Doctors prescribe both intravenous and oral antibiotics in the absence of contraindications. These may be drugs such as Ampicillin, Cefotaxime, Ceftriaxone or Ciprofloxacin.
2. Taking herbal preparations. Products based on herbal components can restore the functional abilities of the kidneys, reduce inflammation and stimulate urination.
3. Symptomatic treatment. At high temperatures and severe pain, it is recommended to take antipyretic and painkillers.

Treatment of pyelonephritis can take from a week to several months in particularly complex cases.

Pyelonephritis according to ICD 10 - classification of the disease

Pyelonephritis is an inflammatory disease of the kidneys. The pelvis and tissue (mainly interstitial) are directly affected. People of all ages are affected, but in women, due to structural features, the pathology occurs more often than in men.

According to the International Classification of Diseases, Tenth Revision (ICD-10), the condition is classified in class XIV “Diseases of the genitourinary system”. The class is divided into 11 blocks. The designation of each block begins with the letter N. Each disease has a three-digit or four-digit designation. Inflammatory kidney diseases belong to the headings (N10-N16) and (N20-N23).

Why is the disease dangerous?

1. Inflammatory kidney disease is a common pathology. Anyone can get sick. The risk group is wide: children, young women, pregnant women, elderly men.
2. The kidneys are the body's leading filter. During the day they pass doliters of blood through themselves. Once they get sick, they cannot cope with filtering toxins. Toxic substances re-enter the blood. They spread throughout the body and poison it.

The first symptoms are not immediately associated with kidney disease:

• Increased blood pressure.
• Itching appears.
• Swelling of the limbs.
• Feeling of fatigue inappropriate to the load.

Treatment of symptoms without consultation with specialists, at home, leads to a worsening of the condition.

The disease can be triggered by any factors surrounding a modern person: stress, hypothermia, overwork, weakened immunity, unhealthy lifestyle.

The disease is dangerous because it can become chronic. During exacerbation, the pathological process spreads to healthy areas. As a result of this, the parenchyma dies and the organ gradually shrinks. Its functioning is reduced.

The disease can lead to the formation of kidney failure and the need to connect an “artificial kidney” device. A kidney transplant may be required in the future.

The consequences are especially dangerous - the addition of a purulent infection, necrotization of the organ.

ICD-10 indicates:

Acute pyelonephritis. Code N10

Acute inflammation caused by infection of kidney tissue. Most often it affects one of the kidneys. It can develop either in a healthy kidney or occur against the background of kidney disease, developmental anomalies, or disturbances in the processes of urine excretion.

To identify the infectious agent, an additional code (B95-B98) is used: B95 - for streptococci and staphylococci, B96 - for other specified bacterial agents and B97 - for viral agents.

Chronic pyelonephritis. Code N11

Usually develops due to non-compliance with the therapeutic regimen of an acute condition. As a rule, the patient knows about his illness, but sometimes it can be latent. Symptoms expressed during an exacerbation gradually subside. And it seems that the disease has receded.

In most cases, pathology is detected during clinical examination, during urine analysis in connection with other complaints (for example, high blood pressure) or diseases (for example, urolithiasis).

When collecting anamnesis in these patients, symptoms of previous cystitis and other inflammatory diseases of the urinary tract are sometimes revealed. During exacerbations, patients complain of pain in the lumbar region, low temperature, sweating, exhaustion, loss of strength, decreased appetite, dyspepsia, dry skin, increased blood pressure, pain when urinating, and decreased amount of urine.

Non-obstructive chronic pyelonephritis associated with reflux. Code N11.0.

Reflux is the reverse flow (in this context) of urine from the bladder into the ureters and above. Main reasons:

• Bladder fullness.
• Bladder stones.
• Hypertonicity of the bladder.
• Prostatitis.

Chronic obstructive pyelonephritis. Code N11.1

Inflammation develops against the background of obstruction of the urinary tract due to congenital or acquired anomalies in the development of the urinary system. According to statistics, the obstructive form is diagnosed in 80% of cases.

Non-obstructive chronic pyelonephritis NOS N11.8

With this pathology, the ureters are not blocked by stones or microorganisms. Patency of the urinary tract is preserved, urination is not impaired either qualitatively or quantitatively.

Pyelonephritis NOS. Code N12

The diagnosis is made without additional specifications (acute or chronic).

Calculous pyelonephritis. Code N20.9

Develops against the background of kidney stones. If you identify the presence of stones in time and begin treatment, you can avoid chronicity of the disease.

Stones may not make themselves felt for years, making their diagnosis difficult. The appearance of severe pain in the lumbar region means only one thing - it’s time to contact a qualified specialist. It is sad that most patients are reluctant to consult a doctor at the first symptoms of the disease.

From the above it follows that this disease is a real chameleon among other pathologies. Insidious in its love to take the guise of other diseases, it can end sadly. Listen to your body. Do not drown out pain and other symptoms with self-medication. Seek help promptly.

Pyelonephritis in children

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)

Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan

general information

Short description

DMSA dimercaptosuccinic acid

Classification

Diagnostics

List of basic and additional diagnostic measures

Blood pressure measurement

Biochemical urine analysis (daily excretion of protein, oxalates, urates, calcium, phosphorus)

Immune status study

Feces for dysbacteriosis

General urine analysis (1st, 3rd, 7th, 14th days, then individually) or urine analysis according to Nechiporenko with minimal changes in the general analysis

Urine culture for flora and sensitivity to antibiotics (before starting ABT)

Clinical blood test

Determination of CRP in blood serum

Biochemical blood test (total protein and fractions, creatinine, urea, uric acid)

Calculation of GFR according to Schwartz

Ultrasound of the kidneys and bladder before and after miction under conditions of physiological hydration

Urine tests for urogenital infection (chlamydia, mycoplasma, ureaplasma)

Virological examination (HSV, CMV, Epstein-Barr virus)

Urine culture for fungal and anaerobic infections

Rhythm and volume of spontaneous urination, taking into account the liquid drunk

Test with furosemide and water load

Excretory urography (not performed in case of reduced GFR and creatinemia)

Urine analysis according to Zimnitsky

Titratable acidity study

Microalbumin, β2-microglobulin, α1-microglobulin in urine

Fermenturia (LDG, GGT, ALP, etc.)

Static renoscintigraphy (not earlier than 6 months after relief of clinical and laboratory signs of pyelonephritis)

Chills, fever 38°C;

General weakness, malaise, refusal to eat

There may be pain in the lumbar region

Symptoms of dysuria and edema may appear.

Body temperature is low-grade or normal

On palpation, positive Pasternatsky syndrome

Increase in ESR 20 mm/hour;

Increased CRPmg/l;

Increased serum PCT 2 ng/ml.

Ultrasound of the kidneys: congenital malformations, cysts, stones

Cystography - vesicoureteral reflux or condition after antireflux surgery

Nephroscintigraphy - lesions of the renal parenchyma

For tubulointerstitial nephritis - diagnostic puncture biopsy of the kidney (with parental consent)

Consultation with a urologist, pediatric gynecologist

According to indications, consultation with an andrologist, ophthalmologist, otolaryngologist, phthisiatrician, clinical immunologist, dentist, neurologist

Obstructive pyelonephritis - a pathology associated with blockage of the urinary tract

Obstructive pyelonephritis may initially not be associated with an infectious process, but later bacterial inflammation joins it. Treatment of this disease can be difficult, depending on what caused it.

Obstructive pyelonephritis

Obstructive pyelonephritis is understood as inflammation of the renal pelvis or calyces associated with difficulty in the outflow of urine from the organ. In other words, if the urinary tract in the kidneys is blocked by stones, a tumor, or for other reasons, an inflammatory process occurs - pyelonephritis. In rare cases, pathology occurs independently; much more often it manifests itself against the background of another disease.

The main manifestations of the pathology are pain, urination problems and high body temperature. Obstructive pyelonephritis occurs more often in adults; in childhood, the pathology is much less common.

Ordinary acute nephritis can also develop into obstructive pyelonephritis - with prolonged absence of treatment, when inflammatory products clog the pathways of urine excretion from the kidneys. The disease can be complicated by a deadly pathology - renal failure.

Forms

Primary obstructive pyelonephritis is a disease that initially affects the kidney, leading to the development of an inflammatory process and narrowing or complete closure of the urinary tract. But most often secondary obstructive pyelonephritis occurs - it occurs as a complication of other diseases.

The classification of pyelonephritis according to the localization of the inflammatory process is as follows:

According to the type of course, pyelonephritis can be acute or chronic. The acute process develops for the first time, has vivid symptoms, and is often difficult. Chronic obstructive pyelonephritis is accompanied by periodic relapses and remissions.

Causes and pathogenesis

In most cases, the pathology occurs due to decreased immunity in the kidneys against the background of long-acting factors, as well as due to stagnation of urine, which leads to the following problems:

1. Nephrolithiasis, or urolithiasis. This is the most common cause of urinary tract obstruction. Stones can form in the bladder or in the system of cups and pelvises, but with the flow of urine they can move and clog any part of the system. Often the stone closes the lumen of the ureter, so stagnation of urine forms in the renal tissue and pelvis.
2. Neoplasms of the kidney, ureter, as well as tumors of neighboring organs, including the intestines. Compression of the urine outflow tract causes obstruction and subsequent inflammation.
3. Congenital anomalies of the structure of the kidneys and ureters. Narrowings and strictures of the ureters hold the lead in this group of causes; they are also the determining risk factors for the development of pyelonephritis in children. Anomalies in the structure of the organs of the urinary system can also be acquired, for example, appearing after injuries or operations.
4. Benign prostatic hyperplasia. The lumen of the urethra, compressed by prostate adenoma, narrows, which causes stagnation of urine, the development of inflammation and its rise to the kidneys.
5. Foreign bodies. Very rarely, but experts diagnose blockage of the urinary tract in young children by foreign objects. This reason may also have an effect in open kidney injury.

Urolithiasis or structural anomalies of the kidneys are characterized by a long course and partial obstruction, so they become the basis for the development of chronic pyelonephritis. However, changing the position of the stone can provoke an exacerbation of pyelonephritis. Tumors are characterized by increasing obstruction, which can lead to the development of both forms of pyelonephritis.

Infection can penetrate into the site of stagnation of urine in two ways - hematogenous (with blood flow from other sources of infection) and, much more often, urogenic. In the second case, inflammation begins in the urethra or bladder and then penetrates the kidneys. It happens that an infectious process in the kidneys already takes place - this happens in patients with chronic non-obstructive pyelonephritis.

Inflammation can be caused by representatives of pathogenic and opportunistic microflora, such as:

• Staphylococcus;
• Enterococci;
• Escherichia coli;
• Pseudomonas aeruginosa;
• Proteus;
• Streptococci;
• Mixed microflora (2/3 cases).

If a patient has chronic pyelonephritis, over time the tissue in the affected areas of the kidney dies and is replaced by scars, therefore, the kidney parenchyma decreases - organ dysfunction occurs with the development of renal failure.

Symptoms

Acute obstructive pyelonephritis in children and adults begins acutely - with sharp pain in the lumbar region. When the ureter is blocked by a stone, renal colic occurs with unbearable pain, for which analgesics do not help much. The pain radiates to the groin and thigh. There are also signs of high body temperature (up to 40 degrees), profuse sweating, and they appear already against the background of renal colic - by the end of the first day.

On the side of the affected organ (left or right), there is tension in the anterior wall of the peritoneum, and there is severe pain on palpation in the projection of the kidney. There are disturbances in the process of urination, retention of urine, and sometimes there is blood in the urine. The person complains of weakness, malaise, headache, nausea, and often vomiting. Signs of intoxication reach their maximum 3-4 days after the onset of pain in the kidney.

In chronic obstructive pyelonephritis, the pain is aching, occurring regularly, and not intense. General weakness, decreased performance, increased urge to urinate, and discomfort when going to the toilet are also observed. With a long-term illness, a person may develop urinary incontinence.

Diagnostics

In making a diagnosis, the main role is played by collecting anamnesis and clarifying the existing chronic kidney pathology (strictures, nephrolithiasis, etc.), as well as comparing the anamnesis with current clinical signs. During a physical examination, pain in the affected area, impaired mobility of the kidney and its enlargement due to edema, and tension in the muscles of the back and abdomen are revealed.

Laboratory and instrumental diagnostic methods include the following:

1. General urine analysis. Protein, a moderate number of red blood cells, and a large number of leukocytes appear in the urine.
2. Bacteriological culture of urine. Bacteria that cause the inflammatory process are identified.
3. General blood analysis. There is an increase in leukocytes, ESR, neutrophils, as well as anemia.
4. Survey radiography. There is an enlargement of the kidney, visually noticeable tumors, stones, strictures, and foreign bodies.
5. Ultrasound of the kidneys. Makes it possible to detect all inflammatory foci in the kidneys, zones of destruction in chronic pyelonephritis, and establish the cause of the pathology.
6. MRI, CT. Most often they are recommended for differentiating kidney tumors or clarifying the type of stones for choosing treatment.

Treatment

To eliminate the cause of the disease and the resulting inflammatory process, in most cases a combined method is used. Kidney stones are removed using surgery or minimally invasive stone crushing techniques. If the urinary tract is completely blocked, emergency surgery is most often performed. For tumors of the kidneys and surrounding organs, whenever possible, surgery, radiation therapy, and chemotherapy are performed. Ureteral strictures and other structural anomalies of the urinary system in children and adults are removed through endoscopic surgery.

Conservative treatment is aimed at eliminating the infectious process and relieving symptoms. The following types of drugs are used:

1. Antispasmodics – belladonna extract, Platyfillin, No-spa.
2. Anti-inflammatory drugs - Ibuprofen, Nurofen.
3. Antibiotics of targeted action - Negram, Nevigramon, as well as uroseptics - Furadonin, Furomag.
4. Broad-spectrum antibiotics - Ampicillin, Oletetrin, Kanamycin, Tseporin, Tetracycline.

For chronic obstructive pyelonephritis, in addition to these drugs, immunomodulators (Urovaxom) and herbal anti-inflammatory drugs (Canephron) are recommended. In children with severe disease, treatment with hormonal anti-inflammatory drugs (Prednisolone) is often practiced. In general, treatment of a chronic form of pathology can be carried out for years using various antibiotics and antiseptics, alternating and combining with each other. It is useful to use cranberries, the extract of this berry and preparations based on it in therapy. Treatment in sanatoriums and physiotherapy (electrophoresis, magnetotherapy, SMV therapy) are indicated.

The diet should reduce the load on the kidneys and help normalize the outflow of urine. You should avoid salty, fatty foods, spicy and fried foods, confectionery, and baked goods. You need to drink a lot of fluid - from 2.5 liters per day.

Prognosis and complications

An acute obstructive process in the kidneys threatens the development of renal failure, necrosis of the renal papillae, and paranephritis. Rare, but the most dangerous complications are sometimes sepsis and bacterial shock. In the chronic form of the pathology, patients often suffer from nephrogenic arterial hypertension and chronic renal failure. The prognosis largely depends on the cause of the disease and the speed of medical care. Congenital anomalies of organ structure are usually successfully corrected, as are most forms of urolithiasis. For tumor pathologies of the kidneys, the prognosis depends on the stage of the disease and the type of tumor.

Acute pyelonephritis

Although acute pyelonephritis is defined as inflammation of the kidney and renal pelvis, this diagnosis is clinical. The term “urinary tract infection” is used in cases where infection is certainly present, but there are no obvious signs of direct kidney damage. The term “bacteriuria” is used to indicate that bacteria are not only constantly present in the urinary tract, but also actively multiply.

ICD-10 code

Causes of acute pyelonephritis

Acute pyelonephritis is an acute bacterial infection manifested by inflammation of the pelvis and kidney parenchyma. Most often, urinary tract infections are caused by bacteria that live in the colon. 80 to 90% of primary urinary tract infections are caused by Escherichia coli, which is present in large quantities in stool.

Escherichia coli strains isolated during bacteriological examination of urine are also found on the skin around the external opening of the urethra, in the vagina, and in the rectum. Not all strains of E. coli have virulence factors. Of the numerous strains of Escherichia coli (over 150), only some are uropathogenic, in particular serotypes 01.02.04.06,07,075.0150.

Frequent pathogens of urinary infections also include other gram-negative (Klebsiella pneumoniae, Enterobacter aerogenes/agglomerans; Proteus spp.) and gram-positive (Enterococcus faecalis, Staphylococcus saprophyticus) bacteria of the Enterobacteriaceae family. Anaerobic bacteria, which are present in much larger numbers in the intestines, rarely affect the kidneys. It should also be noted that chlamydia and ureaplasma do not act as causative agents of acute pyelonephritis. Diseases such as atrophic vaginitis, sexually transmitted diseases (caused by chlamydia, gonococci, herpesvirus infection), as well as candidiasis and trichomonas vaginitis, which also cause frequent urination, are not classified as urinary tract infections.

Among pathogenic pathogens, Proteus mirabilis plays an important role. It produces urease, which breaks down urea into carbon dioxide and ammonia. As a result, the urine becomes alkaline and tripelphosphate stones are formed. The bacteria that settle in them are protected from the action of antibiotics. The proliferation of Proteus mirabilis promotes further alkalinization of urine, precipitation of tripel phosphate crystals and the formation of large coral stones.

Urease-producing microorganisms also include:

• Ureaplasma urealyticum:
• Proteus spp.
• Staphylococcus aureus;
• Klebsiella spp.
• Pseudomonas spp.
• E. coli.

Mixed urinary tract infections, when several pathogens are isolated from urine, are rare in primary acute pyelonephritis. However, in complicated acute pyelonephritis caused by hospital (nosocomial) strains of microorganisms, especially in patients with various catheters and drainages, stones in the urinary tract, after intestinal plastic surgery of the bladder, a mixed infection is often isolated.

Pathogenesis

The development of acute bacterial pyelonephritis, of course, begins with the introduction of bacteria into the urinary tract. Further, the process proceeds depending on the factors inherent in the micro- and macroorganism and their interaction. The state of general and local defense mechanisms determines susceptibility to urinary tract infections. The corresponding anatomical lesion in the kidney consists of a significant number of polymorphonuclear leukocytes in the interstitial space of the kidney and the lumen of the tubules, sometimes in sufficient density to form an abscess. Abscesses may be multifocal, suggesting metastatic spread from the bloodstream (bacteremia), or, more commonly, appear as a focal infection radiating from the renal papilla within a segment of the kidney, forming a wedge-shaped lesion that extends into the renal cortex (ascending infection).

With significantly severe acute pyelonephritis (acute lobar nephronia), intravenous urograms, computed tomograms or ultrasound scans can show a localized, fluid-free protrusion involving one or more renal lobes. The lesion may be difficult to distinguish from a tumor or abscess.

There are 3 known ways of penetration of pathogenic microorganisms into the urinary tract:

• ascending (colonization of the external opening of the urethra by bacteria of the intestinal group, from where they penetrate into the urethra and bladder);
• hematogenous (for example, screening of the pathogen into the kidneys with the formation of an abscess during staphylococcal bacteremia;
• contact (spread of microorganisms from neighboring organs, for example, with a vesico-intestinal fistula, the formation of a bladder from a segment of the intestine).

Bacteria usually do not penetrate the urinary tract through glomerular filtration.

The most common path is upward. Through the short female urethra, uropathogenic microorganisms that colonize its external opening easily penetrate the bladder, especially during sexual intercourse, which is why urinary tract infections are more common in women who are sexually active. In men, the risk of ascending infections is less due to the greater length of the urethra, the distance of its external opening from the anus and the antimicrobial properties of prostate secretions. In infant boys with uncircumcised foreskin, in young men who are sexually active, and in older men, the accumulation of bacteria in the folds of the foreskin, poor hygiene and fecal incontinence contribute to the colonization of the urinary tract by uropathogenic bacteria. Bladder catheterization and other endoscopic interventions on the urinary tract increase the risk of infection in both sexes. After a single catheterization, the risk is 1-4%; with continuous catheterization and the use of open drainage systems, infection of the urine and urinary tract inevitably occurs within a few days.

Microorganisms, including mycobacteria and fungi, can penetrate the kidneys, bladder and prostate through the hematogenous route from the primary site of infection in other organs (for example, kidney abscess and paranephritis caused by staphylococci or streptococcus pyogenes). Direct spread of infection from the intestine to the bladder occurs with vesico-intestinal fistulas (as a complication of diverticulitis, colon cancer, Crohn's disease), while a large number of different types of enterobacteria (mixed infections), gas (pneumaturia) and feces are often found in the urine.

Until now, in the domestic literature it is generally accepted that the main and almost the only way of infection of the kidney is hematogenous. This idea has been artificially created since the time of Moskalev and other experimenters who injected animals with a pathogen intravenously, while creating supravesical obstruction of the ureter by ligating it. However, even the classics of urology at the beginning of the last century, topical forms of acute infectious and inflammatory process in the kidney were clearly divided into “pyelitis, acute pyelonephritis and purulent nephritis.” Most authors of modern foreign literature, as well as WHO experts, in their latest classification (ICD-10), consider the urinogenic route of kidney infection to be the main one.

The ascending (urinogenic) route of infection has been confirmed in experimental work by a large number of domestic and foreign researchers. It was shown that bacteria (Proteus, Escherichia coli and other microorganisms of the Enterobacteriaceae family) introduced into the bladder rapidly multiply and spread up the ureter, reaching the pelvis. The fact of an ascending process in the lumen of the ureter was proven by fluorescent microscopy on the bacteria Teplitz and Zangwill. From the pelvis, microorganisms, multiplying, reach the medulla and spread towards the renal cortex.

The introduction of microorganism cultures into the bloodstream has convincingly shown that microorganisms do not penetrate from the bloodstream into the urine through intact kidneys, i.e. The concept that is still generally accepted among doctors that a carious tooth can be the cause of acute pyelonephritis does not stand up to criticism both for this reason and for the various causative agents of acute pyelonephritis and caries.

The predominantly ascending route of infection of the urinary tract and kidney also corresponds to clinical data: a high frequency of unilateral uncomplicated acute pyelonephritis in women, an association with cystitis, the presence of P-fimbriae in Escherichia coli, with the help of which it adheres to the urothelial cell, and the genetic identity of bacteria isolated from women with primary acute pyelonephritis from urine, feces and vagina.

Various topical forms of acute inflammation of the kidney are also characterized by different ways of infection: for pyelitis, the ascending (urinogenic) route of infection is common, for pyelonephritis - urinogenic and urinogenic-hematogenous, for purulent nephritis - hematogenous.

The hematogenous route of infection or reinfection of the kidney can complicate the course of uncomplicated urinogenic acute pyelonephritis with the development of bacteremia, when the source of infection in the body is the affected kidney itself. According to the international multicenter study PEP-study, in acute pyelonephritis, the diagnosis of urosepsis in different countries is established in 24%, and according to researchers, in only 4%. Obviously, in Ukraine they underestimate the severity of purulent acute pyelonephritis, complicated by bacteremia, which foreign authors interpret as urosepsis.

Risk factors for the development of kidney abscess include a history of urinary tract infection, urolithiasis, vesicoureteral reflux, neurogenic bladder dysfunction, diabetes mellitus and pregnancy, as well as the properties of the microorganisms themselves, which produce and acquire pathogenicity genes, high virulence genes and resistance to antibacterial drugs. The location of the abscess depends on the route of infection. With hematogenous spread, the renal cortex is affected, and with ascending, as a rule, the medulla and cortex are affected.

The course of acute pyelonephritis and the risk of complications are determined by the primary or secondary nature of the infection. Primary (uncomplicated) acute pyelonephritis responds well to antibiotic therapy and does not lead to kidney damage. Severe primary acute pyelonephritis can lead to cortical shrinkage, but the long-term effect of this complication on renal function is unknown. With secondary kidney infections, severe damage to the kidney parenchyma, abscess and paranephritis are possible.

Symptoms of acute pyelonephritis

Symptoms of acute pyelonephritis can vary from sepsis caused by gram-negative bacteria to signs of cystitis with mild pain in the lumbar region.

Symptoms of acute pyelonephritis most often manifest themselves in mild local signs of inflammation. The patient's condition is moderate or severe. The main symptoms of acute pyelonephrthia are as follows: malaise, general weakness, fever up to ° C, chills, sweating, pain in the side or lumbar region, nausea, vomiting, headache.

Symptoms of cystitis are often observed. Characterized by pain upon palpation and tapping in the costovertebral angle on the affected side, facial redness, and tachycardia. Patients with uncomplicated acute pyelonephritis usually have normal blood pressure. Patients with acute pyelonephritis associated with diabetes mellitus, structural or neurological abnormalities may have hypertension. Micro- or macrohematuria is possible in 10-15% of patients. In severe cases, urosepsis caused by gram-negative bacteria, necrosis of the renal papillae, acute renal failure with oliguria or anuria, kidney abscess, and paranephritis develop. Bacteremia is detected in 20% of patients.

In secondary complicated acute pyelonephritis, including in hospitalized patients and patients with indwelling urinary catheters, clinical symptoms of acute pyelonephritis range from asymptomatic bacteriuria to severe urosepsis and infectious-toxic shock. Deterioration of the condition may begin with a sharp increase in pain in the lumbar region or an attack of renal colic due to a violation of the outflow of urine from the renal pelvis.

Hectic fever is characteristic, when hyperthermia up to °C is replaced by a critical drop in body temperature to subfebrile levels with heavy sweating and a gradual decrease in the intensity of pain, until complete disappearance. However, if the obstruction to the outflow of urine is not eliminated, the patient’s condition worsens again, the pain in the kidney area intensifies and fever with chills reappears. The severity of the clinical picture of this urological disease varies depending on age, gender, previous condition of the kidneys and urinary tract, the presence of hospitalizations before the current admission, etc. In elderly and senile patients, in debilitated patients, as well as in the presence of severe concomitant diseases against the background of an immunosuppressive state, the clinical manifestations of the disease are erased or distorted.

In children, symptoms of acute pyelonephritis manifest themselves in the form of fever, vomiting, abdominal pain, and sometimes loose stools. In infants and young children, the symptoms of acute pyelonephritis may be subtle and include only excitability and fever. The mother may notice an unpleasant smell of urine and signs of straining when urinating. The diagnosis is made if pus, white blood cells and bacteria are found in the analysis of freshly passed urine.

The causative agents of complicated urinary tract infections are often mixed, more difficult to treat, more virulent and resistant to antibacterial drugs. If a hospitalized patient suddenly develops signs of septic shock (especially after bladder catheterization or endoscopic urinary tract procedures), even in the absence of symptoms of a urinary tract infection, urosepsis should be suspected. With complicated (secondary) urinary tract infections, the risk of urosepsis, necrosis of the renal papillae, kidney abscess and paranephritis is especially high.

Where does it hurt?

Diagnosis of acute pyelonephritis

The diagnosis of uncomplicated (non-obstructive) acute pyelonephritis is confirmed by a positive culture bacteriological examination of urine (microbial count - over 10 4 CFU/ml), associated with pyuria. This clinical syndrome actually occurs only in women, most often between the ages of 18 and 40 years. Approximately 50% of patients with low back pain and/or fever have bacteriuria from the lower urinary tract. Conversely, often in patients with symptomatic or asymptomatic cystitis, the source of bacteriuria may be the upper urinary tract. Approximately 75% of patients with uncomplicated acute pyelonephritis have a history of lower urinary tract infection.

Clinical diagnosis of acute pyelonephritis

Diagnosis of acute pyelonephritis is important, due to the severity of the patient’s condition, identifying urinary tract obstruction. Sometimes it is difficult to determine the stage of development of the infectious-inflammatory process in the kidney, which does not always correspond to the clinical picture of the disease. Although lower and upper urinary tract infections are differentiated based on clinical data, it is impossible to accurately determine the location of the infection based on them. Even signs such as fever and pain in the side are not strictly diagnostic for acute pyelonephritis, as they occur with lower urinary tract infection (cystitis) and vice versa. Approximately 75% of patients with acute pyelonephritis had a history of previous lower urinary tract infections.

Physical examination often reveals muscle tension with deep palpation in the costovertebral angle. Acute pyelonephritis can simulate gastrointestinal symptoms with abdominal pain, nausea, vomiting and diarrhea. Asymptomatic progression of acute pyelonephritis into its chronic course in the absence of obvious symptoms can occur in patients with immune deficiency.

Laboratory diagnosis of acute pyelonephritis

Diagnosis of acute pyelonephritis is based on a general urinalysis and bacteriological examination of urine for microflora and sensitivity to antibacterial drugs. If acute pyelonephritis is suspected, it is necessary, in addition to clinical symptoms, to use methods to clarify the localization of the infection.

A general blood test usually reveals leukocytosis with a shift in the leukocyte formula to the left. Serum urea and creatinine concentrations are usually within normal limits. Patients with long-term complicated infection may have azotemia and anemia if both kidneys are involved in the inflammatory process. Proteinuria is also possible, both in uncomplicated and complicated acute pyelonephritis. A decrease in the concentrating ability of the kidneys is the most consistent sign of acute pyelonephritis.

Proper collection of urine for testing is of great importance. Contamination of urine by microflora of the urethra can be avoided only with suprapubic puncture of the bladder. In this way, urine can be obtained from infants and patients with spinal cord damage. In other cases, they resort to it when it is impossible to obtain urine by other means.

For the study, take an average portion of urine during spontaneous urination. In men, the foreskin is first retracted (in uncircumcised) and the head of the penis is washed with soap and water. The first 10 ml of urine is flushed from the urethra, then urine from the bladder. Women are much more likely to become contaminated.

In urine tests, leukocyturia and bacteriuria are not detected in all patients with acute pyelonephritis. When examining urine in patients with a predominantly cortical location of foci of infection (apostematous acute pyelonephritis, kidney abscess, perinephritic abscess) or with obstructive acute pyelonephritis (when the flow of urine from the affected kidney is blocked), leukocyturia and bacteriuria may not be present.

In urine tests, red blood cells may indicate the presence of necrotizing papillitis. stones in the urinary tract, inflammation in the neck of the bladder, etc.

If acute pyelonephritis is suspected, a bacteriological analysis of urine for microflora and sensitivity to antibiotics is required. A microbial titer of 10 4 CFU/ml is considered to be diagnostically significant for the diagnosis of uncomplicated acute pyelonephritis in women. With urine culture, identification of microorganisms is possible only in a third of cases. In 20% of cases, the concentration of bacteria in the urine is below 10 4 CFU/ml.

Patients also undergo a bacteriological blood test for microflora (the result is positive in 15-20% of cases). A culture test of microorganisms in the blood, especially when many microorganisms are detected, more often indicates a perinephric abscess.

Thus, quite often antibacterial treatment is prescribed empirically, i.e. based on knowledge of bacteriological monitoring data in the clinic (department), data on pathogen resistance, based on clinical studies known from the literature and our own data.

Instrumental diagnosis of acute pyelonephritis

Diagnosis of acute pyelonephritis also includes radiation diagnostic methods: ultrasound scanning, x-ray and radionuclide methods. The choice of method, sequence of application and volume of research must be sufficient to establish a diagnosis, determine the stage of the process, its complications, identify the functional state and urodynamics of the affected and contralateral kidneys. Among diagnostic methods, ultrasound scanning of the kidneys ranks first. However, if necessary, the study begins with chromocystoscopy to identify urinary tract obstruction or with an X-ray examination of the kidneys and urinary tract.

Ultrasound diagnosis of acute pyelonephritis

The ultrasound picture of acute pyelonephritis varies depending on the stage of the process and the presence or absence of obstruction of the urinary tract. Primary (non-obstructive) acute pyelonephritis in the initial period, in the phase of serous inflammation, may be accompanied by a normal ultrasound picture when examining the kidneys. With secondary (complicated, obstructive) acute pyelonephritis at this stage of inflammation, only signs of obstruction of the urinary tract can be detected: an increase in the size of the kidney, expansion of its calyces and pelvis. As the infectious-inflammatory process progresses and interstitial edema increases, the echogenicity of the renal parenchyma increases, and its cortex and pyramids are better differentiated. With apostematous nephritis, the ultrasound picture may be the same as during the phase of serous inflammation. However, the mobility of the kidney is often reduced or absent, sometimes the boundaries of the kidney lose clarity, the cortical and medulla layers are less differentiated, and sometimes shapeless structures with heterogeneous echogenicity are revealed.

With a renal carbuncle, there may be bulging of its external contour, heterogeneity of hypoechoic structures, and lack of differentiation between the cortical and medulla layers. When an abscess forms, hypoechoic structures are identified and the fluid level and abscess capsule are sometimes observed. When paranephritis occurs when the purulent process extends beyond the fibrous capsule of the kidney, echograms show a picture of a heterogeneous structure with a predominance of echo-negative components. The external contours of the kidney are uneven and unclear.

With various obstructions (stones, strictures, tumors, congenital obstructions, etc.) of the upper urinary tract, dilation of the calyces, pelvis, and sometimes the upper third of the ureter is observed. In the presence of pus and inflammatory detritus, heterogeneous and homogeneous echo-positive structures appear in them. Ultrasound monitoring is widely used for dynamic monitoring of the development of acute pyelonephritis.

X-ray diagnosis of acute pyelonephritis

In the past, excretory urography was mainly used. However, this study detects changes in only 25-30% of patients. Only in 8% of patients with uncomplicated acute pyelonephritis were abnormalities found that influenced management tactics.

X-ray symptoms in non-obstructive acute pyelonephritis in the early stages (serous inflammation) are mild. Intravenous urography is not recommended during the first few days after the onset of acute pyelonephritis for the following reasons:

• the kidney is not able to concentrate the contrast agent;
• a dilated segment of the proximal ureter may be confused with ureteral obstruction;
• RCV can cause acute renal failure in a dehydrated patient.

Intravenous urography is not indicated as a routine evaluation in women with symptomatic urinary tract infection.

Renal function and urodynamics on excretory urograms may be within normal limits. There may be a slight increase in the size of the contours of the kidney and a limitation of its mobility. However, if the process enters a purulent phase with the formation of carbuncles or abscesses, the development of paranephritis, the x-ray picture takes on characteristic changes.

On survey urograms you can see an increase in the size of the contours of the kidney, limitation or absence of its mobility (on inspiration and exhalation), a halo of vacuum around the kidney due to edematous tissue, bulging of the contours of the kidney due to a carbuncle or abscess, the presence of shadows of stones, blurredness, smoothness contours of the psoas major muscle, curvature of the spine due to rigidity of the lumbar muscles and sometimes displacement of the kidney. Excretory urography provides important information about renal function, urodynamics, and X-ray anatomy of the kidneys and urinary tract. Due to inflammation and swelling of the interstitial tissue, 20% of patients experience an enlargement of the kidney or part of it. In the nephrographic phase, striations of the cortical substance are visible. Stagnation of urine in the tubules due to edema and narrowing of the renal vessels slow down the excretion of the contrast agent. In case of obstruction of the urinary tract, symptoms of blockade are identified: “dumb or white” kidney (nephrogram), the contours of the kidney are enlarged, its mobility is limited or absent. With partial obstruction of the urinary tract, excretory urograms can show dilated calyces, pelvis, and ureter to the level of obstruction. The retention of RKV in the dilated cavities of the kidney can be observed for a long time.

In acute necrotizing papillitis (with urinary tract obstruction or diabetes mellitus), it is possible to see destruction of the papillae, eroded contours, deformation of the fornix arches, and penetration of the contrast agent into the renal parenchyma like tubular refluxes.

CT scan

CT together with ultrasound sonography is the most specific method for assessing and localizing renal abscess and perinephritic abscess, but the method is expensive. A wedge-shaped, dense area can often be seen on scans, which disappears after several weeks of successful treatment. In acute pyelonephritis, the arterioles narrow, causing ischemia of the renal parenchyma.

Areas of ischemia are identified on contrast-enhanced CT. On tomograms they appear as single or multiple foci of low density. Diffuse kidney damage is also possible. CT scans detect renal displacement and fluid or gas in the perirenal space associated with a perinephric abscess. Currently, CT is a more sensitive method than ultrasound. It is indicated for patients with obstructive acute pyelonephritis, bacteremia, paraplegia, diabetes mellitus, or patients with hyperthermia that does not respond to drug therapy within a few days.

Other X-ray diagnostic methods - nuclear magnetic resonance imaging, angiographic methods for acute pyelonephritis - are rarely used and for special indications. They can be indicated in the differential diagnosis of late purulent manifestations or complications of carbuncles, abscesses, paranephritis, suppurating cysts with tumors and other diseases, if the listed methods do not allow an accurate diagnosis to be established.

Radionuclide diagnostics of acute pyelonephritis

These research methods are rarely used for emergency diagnosis of acute pyelonephritis. They provide valuable information about the function, circulation of the kidneys and urodynamics, but at the stages of dynamic observation and detection of late complications.

Renal scintigraphy has the same sensitivity as CT in detecting ischemia due to acute pyelonephritis. Radiolabeled 11Tc, localized in the cells of the proximal tubules in the renal cortex, makes it possible to visualize the functioning renal parenchyma. Renal scanning is particularly useful in determining renal involvement in children and helps differentiate reflux nephropathy from localized acute pyelonephritis.

On renograms of primary non-obstructive acute pyelonephritis, the vascular and secretory segments are flattened and elongated by 2-3 times, the excretion phase is weakly expressed or cannot be traced. In the phase of purulent inflammation, due to impaired blood circulation, the contrast of the vascular segment is significantly reduced, the secretory segment is flattened and slowed down, and the excretory segment is poorly defined. With total damage to the kidney by a purulent process, an obstructive curved line can be obtained in the absence of obstruction of the upper urinary tract. In case of secondary (obstructive) acute pyelonephritis, renograms at all stages of inflammation can show an obstructive type of curve, the vascular segment is low. the secretory one is slowed down, and the excretory segment is absent on the affected side.

What needs to be examined?

Differential diagnosis

Sometimes a patient with acute pyelonephritis may complain of pain in the lower abdomen, and not the characteristic pain in the side or in the kidney area. Acute pyelonephritis may be confused with acute cholecystitis, appendicitis, or diverticulitis and the occasional presence of bacteriuria and pyuria. Appendicular, tubo-ovarian diverticular abscesses adjacent to the ureter or bladder may be accompanied by pyuria. Pain from stone passage through the ureter may mimic acute pyelonephritis, but the patient usually does not have fever or leukocytosis. Red blood cells are often detected in the urine without bacteriuria or pyuria, unless, of course, there is a concomitant urinary tract infection.

Who to contact?

Treatment of acute pyelonephritis

Indications for hospitalization

In the absence of nausea, vomiting, dehydration and symptoms of sepsis (a systemic generalized reaction of the body), treatment of acute pyelonephritis is carried out on an outpatient basis, but on the condition that the patient follows the doctor’s instructions. In other cases, patients with primary pyelitis and acute pyelonephritis (as well as pregnant women) are hospitalized.

Drug treatment of acute pyelonephritis

For all forms of acute pyelonephritis, bed rest is indicated.

Antibacterial treatment of acute pyelonephritis is prescribed to outpatients for a period of 2 weeks. The European Urological Association guidelines (2006) recommend mild acute pyelonephritis as first-line therapy in regions where the incidence of E. coli resistance to fluoroquinolones remains low (

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There are many classifications of urinary tract and genitourinary infections. At the same time, the classifications of acute pyelonephritis adopted in Russia distinguish only the stages of an acute infectious-inflammatory process in the interstitium and in the parenchyma of the kidney (serous, purulent), but not topical forms of damage to the kidney itself or the renal pelvis, and damage to the pelvis is not reflected at all in these classifications, which contradicts the very concept of “pyelonephritis”.

Classification of pyelonephritis according to S. Kunin (1997):

• acute complicated bacterial pyelonephritis (focal or diffuse);
• lobar nephronia;
• chronic complicated bacterial pyelonephritis;
• emphysematous pyelonephritis:
• papillary necrosis of the kidneys;
• xanthogranulomatous pyelonephritis;
• malakoplakia;
• Lenta pyelonephritis (infection localized in the upper urinary tract);
• kidney abscess and perinephric abscess;
• infection superimposed on polycystic kidney disease;
• kidney infection caused by less common microorganisms;
• kidney tuberculosis and other mycobacterial infections;
• fungal infections;
• viral infections.

Classification of urinary tract and genitourinary organ infections according to the Guidelines of the European Urological Association (2006):

• uncomplicated lower urinary tract infections (cystitis);
• uncomplicated pyelonephritis;
• complicated urinary tract infection with and without pyelonephritis;
• urosepsis;
• urethritis;
• special forms: prostatitis, epididymitis and orchitis.

According to the course, uncomplicated (primary) and complicated (secondary, recurrent) urinary tract infections are distinguished. The term “chronic” for urinary tract infections is usually not used, since in most cases it does not correctly reflect the course of the disease. As a rule, chronic pyelonephritis develops after a bacterial infection that occurs against the background of anatomical abnormalities of the urinary tract (obstruction, vesicoureteral reflux), infected stones. It is believed that up to 60% of human infections are associated with biofilm infection. Biofilm infection refers to the adhesion of microorganisms to the surface of mucous membranes, stones or biomaterials (catheters, drainages, artificial prostheses, sphincters, meshes, etc.). At the same time, microorganisms begin to live and reproduce on them, periodically developing aggression against the host - the macroorganism.

Young women are more likely to suffer from uncomplicated infections; for complicated (secondary) infections there is no such difference. Complications of infections arise against the background of functional disorders or anatomical abnormalities of the urinary tract, after catheterization of the bladder or renal pelvis and interventions on the urinary tract, against the background of severe concomitant diseases: diabetes mellitus, urolithiasis, chronic renal failure, etc. In 30% of cases, secondary or complicated infections are of nosocomial (hospital, nosocomial) origin. Finally, secondary infections are less treatable, often recur, are associated with a higher risk of damage to the renal parenchyma, the occurrence of kidney abscess and urosepsis, and among the pathogens there are more often strains of microorganisms resistant to antibacterial drugs.

Among recurrent urinary tract infections, recurrent (true relapses), repeated (reinfections) and resistant or asymptomatic bacteriuria are distinguished.

Classification. Flow.. Acute: serous or purulent.. Chronic: latent and recurrent (occurs with exacerbations). Primary (developed in a healthy kidney without urodynamic disturbances) and secondary (developed against the background of kidney disease, developmental abnormalities or urodynamic disturbances: ureteral stricture, benign prostatic hyperplasia, urolithiasis, urinary tract atony, reflux dyskinesia). Phases: exacerbation (active pyelonephritis), remission (inactive pyelonephritis). Localization: unilateral (rare), bilateral. With the presence of arterial (symptomatic) hypertension. Complications: uncomplicated (usually in outpatients), complicated - abscess, sepsis (more often in inpatients, during catheterizations, in case of urodynamic disorders - urolithiasis, polycystic kidney disease, benign prostatic hyperplasia, in immunodeficiency states - diabetes, neutropenia). Kidney function - intact, impaired function, chronic renal failure. Community-acquired pyelonephritis (outpatient) and hospital-acquired (nosocomial) - developed within 48 hours of hospital stay. Special clinical forms.. Pyelonephritis of newborns and children.. Pyelonephritis of the elderly and senile age.. Gestational pyelonephritis - pregnant, childbirth, postpartum.. Calculous pyelonephritis.. Pyelonephritis in patients with diabetes.. Pyelonephritis in patients with spinal cord lesions.. Xanthogranulomatous pyelonephritis. (rare) .. Emphysematous pyelonephritis (rare), caused by gas-forming bacteria with the accumulation of gas bubbles in the tissues of the kidney and surrounding tissue.

Statistical data. The incidence rate is 18 cases per year per 1000 population. Women get sick 2-5 times more often than men, girls - 6 times more often than boys. In older men with benign prostatic hyperplasia, pyelonephritis occurs more often than in younger men.
Etiology. In acute pyelonephritis, monoflora is more common, in chronic - associations of microbes. Escherichia coli (75%), Proteus mirabilis (10-15%), Klebsiella and Enterobacter, Pseudomonas, Serratia, Enterococcus, less often - Candida albicans, Neisseria gonorrhoeae, Trichomonas vaginalis, Staphylococcus and Mycobacterium tuberculosis. In case of community-acquired pyelonephritis, E. coli is cultured in 80% of cases; in case of hospital-acquired pyelonephritis, it also predominates, but the frequency of coccal flora increases.
Pathogenesis. Urodynamic disorders. Pre-existing kidney disease, especially interstitial nephritis. Immunodeficiency conditions (treatment with cytostatics and/or prednisolone, diabetes, defects in cellular and humoral immunity). Hormonal imbalance (pregnancy, menopause, long-term use of contraceptives). Routes of infection.. Hematogenous - from an extrarenal lesion (felon, boil, sore throat), with septicemia.. Ascending - from the lower urinary tract along the wall of the ureter in the presence of refluxes (vesicoureteral, ureteropelvic, pelvic-renal), after cystoscopy .
Pathomorphology. In acute pyelonephritis, the kidney is enlarged in size and the capsule is thickened. In the interstitial tissue (cortex and medulla) there are perivascular leukocyte infiltrates with a tendency to form abscesses. When pustules merge or a vessel is blocked by a septic embolus, necrotizing papillitis, an abscess, and a kidney carbuncle may occur. Chronic pyelonephritis goes through stages from perivascular infiltration, focal sclerosis to kidney shrinkage - the kidney is reduced in size, the surface is lumpy, there are tissue retractions in places of sclerosis, the capsule is fused with the kidney parenchyma, and is difficult to remove.

Symptoms (signs)

CLINICAL MANIFESTATIONS
Acute pyelonephritis often occurs with a clear clinical picture, with purulent pyelonephritis similar to a septic or infectious disease. Febrile fever with chills and profuse sweat. Pain in the lumbar region, tenderness on palpation, Pasternatsky's symptom is positive, on the side of pyelonephritis - tension in the anterior abdominal wall (peritonism phenomenon). Urinary syndrome - polyuria (more often) or oliguria (less often) with loss of fluid through the lungs and skin, dysuria - frequent and painful urination. Intoxication syndrome - headache, nausea, vomiting. With bilateral acute pyelonephritis, the development of acute renal failure is possible.
Chronic pyelonephritis in most patients (50-60%) has a latent course. Low-grade fever, sweating, chilling. Pain in the lumbar region, Pasternatsky's symptom is positive. Urinary syndrome - polyuria, nocturia, less commonly dysuria. Symptoms of intoxication. Arterial hypertension (more than 70% of cases). Anemia (in some patients). Clinical signs of exacerbation- increased body temperature (not always), increased blood pressure, increased or appearance of lower back pain, polyuria, dysuria, nocturia.
Laboratory research. Acute pyelonephritis.. Blood test... Increased ESR, neutrophilic leukocytosis, sometimes leukopenia, shift of the leukocyte formula to the left (with purulent pyelonephritis)... Increased urea and creatinine in the blood (with acute renal failure)... Urine. May be cloudy (mucus, bacteria, desquamated epithelium), leukocyturia (neutrophils), active leukocytes (Sternheimer-Malbin, “pale”, arachnid) - formed in urine with low osmolarity (with hematogenous introduction, infections may be absent in the first days, with obstruction there are no ureters), bacteriuria, proteinuria, erythrocyturia (less commonly, hematuria - with necrosis of the renal papillae), hyposthenuria (hypersthenuria is possible with oliguria). Chronic pyelonephritis. In urine analysis: moderate proteinuria, leukocyturia, bacteriuria, microhematuria, Sternheimer-Malbin cells, active leukocytes, hyposthenuria, alkaline urine reaction (especially characteristic of infection with Proteus, Klebsiella and Pseudomonas species). Bacteriological culture of urine is required (more than 103-5 microbes in 1 ml of urine) with determination of the sensitivity of the isolated microflora to antibiotics.
Instrumental data
. Ultrasound of the kidneys.. In acute pyelonephritis - an increase in size, a decrease in echogenicity, spasm of the renal collecting system, the contours of the kidney are smooth, with a renal carbuncle - a cavity formation in the parenchyma. In chronic pyelonephritis - a decrease in size, an increase in echogenicity, deformation and expansion of the renal collecting system. system, tuberosity of the contours of the kidney, asymmetry of size and contours.. With obstruction of the urinary tract - signs of hydronephrosis on the affected side, stones.
. Plain radiography: an increase or decrease in volume of one of the kidneys, tuberous contours, and sometimes a shadow of a calculus.
. Excretory urography (contraindicated in the active phase, with chronic renal failure).. In acute pyelonephritis - late contrast on the affected side, decreased intensity of contrast, slower removal of contrast.. In chronic pyelonephritis, in addition to these symptoms - expansion and deformation of the calyces and pelvis.
. Angiography: in the early stages - a decrease in the number of small branches of the segmental arteries until their disappearance, in the later stages - the kidney shadow is small, there is no border between the cortical and medulla layers; Deformations of blood vessels, narrowing and reduction in their number are detected.
. Radioisotope renography and scintigraphy: kidney sizes are normal or reduced, isotope accumulation is reduced, the secretory and excretory phases of the curve are lengthened.
. Chromocystoscopy.. In acute pyelonephritis - discharge of turbid urine from the mouth of the ureter of the affected kidney (or both kidneys), slowed or weakened release of indigo carmine on the affected side.. In chronic pyelonephritis, dysfunction of the affected kidney is also determined, however, in many patients, disturbances in the release of indigo carmine are not detected .

Diagnostics

Diagnostics
. The diagnosis of active pyelonephritis (acute or exacerbation of chronic) is made on the basis of the clinical “triad” - fever, lower back pain, dysuria; laboratory data confirm the diagnosis (see above), incl. results of bacteriological urine culture and determination of sensitivity to antibiotics, instrumental data.
. In case of latent pyelonephritis, it is advisable to conduct a prednisolone test (30 mg of prednisolone in 10 ml of 0.9% sodium chloride solution intravenously). The test is positive if, after the administration of prednisolone, the content of leukocytes and bacteria in the urine doubles.
. Urinalysis according to Nechiporenko, the leukocyte formula of urine allows us to differentiate chronic pyelonephritis and glomerulonephritis: .. with glomerulonephritis, the number of erythrocytes exceeds the number of leukocytes, with pyelonephritis the number of leukocytes is higher.. with glomerulonephritis, lymphocytes predominate in the leukocyte formula of the blood, with pyelonephritis - neutrophils.
. With chronic pyelonephritis, the concentrating ability of the kidneys is impaired early (Zimnitsky test), with glomerulonephritis - later, at the stage of development of chronic renal failure.
. Differential diagnosis. Infectious diseases accompanied by fever (typhoid fever, malaria, sepsis). Pyonephrosis. Hydronephrosis. Acute purulent disease of the lower urinary tract. Kidney infarction. Acute glomerulonephritis. Pneumonia. Cholecystitis. Acute pancreatitis. Acute appendicitis. Splenic infarction. Dissecting aortic aneurysm. Shingles.
Accompanying illnesses. Obstruction of the urinary tract. Anomalies of the urinary tract. Pregnancy. Nephrolithiasis. SD. Immunodeficiency states.

Treatment

TREATMENT
Diet. In the acute period - table No. 7a, then No. 7. Fluid consumption up to 2-2.5 l/day. With calculous pyelonephritis, the diet depends on the composition of the stones: with phosphaturia - acidifying urine, with uraturia - alkalizing.
General tactics. Restoration of patency of the upper and lower urinary tracts. Antibacterial therapy - on average 4 weeks (2-6 weeks). Medicines that have an antispasmodic effect (platiphylline, papaverine hydrochloride, belladonna extract, etc.). For oliguria - diuretics. Combating dehydration (with polyuria, fever). For metabolic acidosis - sodium bicarbonate orally or intravenously. Antihypertensive therapy. For chronic pyelonephritis without exacerbation - resort treatment in Truskavets, Essentuki, Zheleznovodsk, Sairm. Surgical treatment - if necessary.
Drug therapy. The goal is to eliminate the activity of the process, eradicate the pathogen. The criterion for the effectiveness of therapy is normalization of clinical and laboratory parameters, abacteriuria. Antibacterial therapy for at least 2 weeks in courses of 7-10 days, empirical (before seeding the pathogen) and targeted (after determining the sensitivity of microflora to antibiotics). Acute community-acquired pyelonephritis - start with semi-synthetic penicillins (ampicillin, amoxicillin; alternative drugs - protected penicillins such as amoxicillin + clavulanic acid, ampicillin + sulbactam) or oral cephalosporins (cephalexin, cefuroxime, cefaclor); it is also possible to prescribe co-trimoxazole, doxycycline.. Acute nosocomial pyelonephritis - start with fluoroquinolones (norfloxacin, ciprofloxacin, ofloxacin, levofloxacin, lomefloxacin); alternative drugs - protected penicillins, cephalosporins of the II-III generation, gentamicin + ampicillin (amoxicillin, carbenicillin), imipenem + cilastatin.. Exacerbation of chronic ambulatory pyelonephritis - start with protected penicillins, drugs of choice - fluoroquinolones, co-trimoxazole, cephalosporins (all drugs for taken orally) .. Exacerbation of chronic nosocomial pyelonephritis - start with fluoroquinolones, drugs of choice besides those mentioned above - imipenem + cilastatin, gentamicin + ampicillin (cephalosporins II-III, azlocillin, carbenicillin, piperacillin), cephalosporins III + protected penicillins .. If staphylococcal infection is suspected pyelonephritis - vancomycin + oxacillin + gentamicin (amikacin).. Anti-relapse therapy carried out for 3-12 months, 7-10 days of each month, for purulent pyelonephritis - with antibiotics (see above), for serous pyelonephritis - with uroantiseptics, alternately: nalidixic acid 0.5-1 g 4 times / day, nitrofurantoin 0 .15 g 3-4 times a day, nitroxoline 0.1-0.2 g 4 times a day. It is also effective to prescribe uroantiseptics once a night: co-trimoxazole, trimethoprim or nitrofurantoin 100 mg at night or 3 times a week (prophylactically). Immunocorrection. For acidosis - sodium bicarbonate 1-2 g orally 3 times a day or 100 ml of 4% solution intravenously. For anemia - iron supplements, blood transfusion, red blood cell transfusion.
Surgery. For purulent pyelonephritis, if conservative therapy fails, decapsulation of the kidney, pyelonephrostomy and drainage of the renal pelvis are performed. The calculus is removed only if the volume of the operation is not significantly increased. Stones from the pelvic ureter are removed when the patient recovers from a serious condition. For kidney carbuncle, dissection of the inflammatory-purulent infiltrate or resection of the affected area of ​​the kidney. For obstructive pyelonephritis, interventions are aimed at eliminating the obstruction to the outflow of urine (for example, removing a stone). For xanthogranulomatous pyelonephritis, partial excision of the kidney is performed.

Complications. Necrosis of the renal papillae. Kidney carbuncle. Apostematous nephritis. Pyonephrosis. Paranephritis. Urosepsis, septic shock. Metastatic spread of purulent infection to the bones, endocardium, eyes, membranes of the brain (with the appearance of epileptic seizures). Secondary parathyroidism and renal osteomalacia (with chronic pyelonephritis due to renal losses of calcium and phosphates). Pyelonephritis wrinkled kidney. Nephrogenic arterial hypertension. Hypotrophy of newborns (with pyelonephritis in pregnant women). Acute and chronic renal failure.
Course and prognosis. The prognosis worsens as the duration of pyelonephritis increases, with nosocomial pyelonephritis, microbial resistance to antibacterial agents, urinary tract obstruction, the presence of purulent complications, immunodeficiency states, and frequent relapses. Complete recovery from acute pyelonephritis is possible with early diagnosis, rational antibiotic therapy, and the absence of aggravating factors. 10-20% of patients with chronic pyelonephritis develop chronic renal failure. In 10% of patients with arterial hypertension, it becomes malignant.
Concomitant pathology. Urolithiasis disease. Kidney tuberculosis. Benign prostatic hyperplasia. Uterine prolapse. Purulent - septic diseases. SD. Spinal disorders.
Pyelonephritis and pregnancy. Acute pyelonephritis affects 7.5% of pregnant women (usually right-sided). In the first pregnancy, pyelonephritis most often begins in the 4th month of pregnancy, in the second pregnancy - in the 6-7th month. Features of the clinical picture: pain in the lower abdomen, dysuria. The disease begins with chills and fever. Intoxication is severe, which is caused by renal pelvic reflux, which occurs as a result of stretching of the renal pelvis. Pyelonephritis during pregnancy is an indication for emergency hospitalization. Termination of pregnancy is indicated only if there is a threat of urosepsis, the development of acute renal failure, or the addition of preeclampsia.

Age characteristics
. Pyelonephritis in childhood.. The disease often occurs against the background of congenital anomalies of the urinary system (stenosis of the urethra, bending of the ureter, etc.), dysmetabolic processes (oxalaturia, uraturia).. Possible rapid onset with high body temperature or latent with low-grade fever fever.. Other symptoms: enuresis, pain or itching in the external genital area in girls, gastrointestinal dysfunction, swelling and pain in the lumbar region.. During treatment, a forced rhythm of urination is additionally prescribed.
. Pyelonephritis in elderly and senile people. The disease proceeds latently. Characterized by decreased reactivity and mild clinical manifestations. Symptoms of general intoxication predominate. In men, pyelonephritis often develops against the background of benign prostatic hyperplasia.
Prevention. Timely treatment of foci of infection. Treatment of urinary tract diseases that obstruct the flow of urine. Regime: rational nutrition, prevention of overwork. Rational treatment of acute pyelonephritis.
Synonyms. Ureteropyelonephritis. Rising jade. Interstitial nephritis.

ICD-10. N10 Acute tubulo - interstitial nephritis. N11 Chronic tubulo-interstitial nephritis.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Chronic obstructive pyelonephritis (N11.1)

Pediatric nephrology, Pediatrics

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Pyelonephritis is a nonspecific bacterial inflammation of the renal parenchyma and collecting system of the kidneys, manifested by a picture of an infectious disease, especially in young children, characterized by leukocyturia and bacteriuria, as well as impaired functional state of the kidneys. According to the classification of the World Health Organization (WHO), pyelonephritis belongs to the group of tubulointerstitial nephritis and is actually tubulointerstitial nephritis of infectious origin

Protocol name- Pyelonephritis in children

Protocol code -

ICD-10 code(s)
N10 Acute tubulointerstitial nephritis
N11 Chronic tubulointerstitial nephritis
N11.0 Non-obstructive chronic pyelonephritis associated with reflux
N11.1 Chronic obstructive pyelonephritis
N11.8 Other chronic tubulointerstitial nephritis
N11.9 Chronic tubulointerstitial nephritis, unspecified
N12 Tubulointerstitial nephritis, not specified as acute or chronic

Abbreviations
UTI, urinary tract infection,
CRP C-reactive protein
GFR glomerular filtration rate
ICD urolithiasis
Ultrasound ultrasound examination
CMV cytomegalovirus
HSV herpes simplex virus
LDH lactate dehydrogenase
GGT gamma-glutamyl transpeptidase
ALP alkaline phosphatase
PCT procalcitonin
compulsory medical insurance organs of the urinary system
VUR vesicoureteral reflux
DMSA dimercaptosuccinic acid

Date of protocol development- April 2013

Protocol users: doctors - pediatricians, general practitioners, parents of children diagnosed with pyelonephritis

No conflict of interest

Classification

Clinical classification of pyelonephritis in children

The course of pyelonephritis can be recurrent:
- rare relapses -<2 обострений за 6 мес или <4 в год;
- frequent relapses - ³2 exacerbations in 6 months or ³4 per year.

Recurrent pyelonephritis is associated with:
- reinfection (new infection);
- persistence of the pathogen - in case of biofilm formation (with urolithiasis, permanent urinary catheter, urostomy, etc.);
- unresolved infection.

Working scheme for diagnosing pyelonephritis:
- Acute or chronic;
- Non-obstructive (without urodynamic disturbances) or obstructive (with urodynamic disturbances);
- Period of remission or exacerbation (the number of exacerbations must be indicated);
- Kidney function: preserved or impaired.

Diagnostics

List of basic and additional diagnostic measures

List of basic diagnostic measures

Physical examination (with mandatory examination of the external genitalia)
- Blood pressure measurement
- Biochemical urine analysis (daily excretion of protein, oxalates, urates, calcium, phosphorus)
- Study of immune status
- Feces for dysbacteriosis
- General urine analysis (1st, 3rd, 7th, 14th days, then individually) or urine analysis according to Nechiporenko with minimal changes in the general analysis
- Urine culture for flora and sensitivity to antibiotics (before starting ABT)
- Clinical blood test
- Determination of CRP in blood serum
- Biochemical blood test (total protein and fractions, creatinine, urea, uric acid)
- Calculation of GFR according to Schwartz
- Ultrasound of the kidneys and bladder before and after miction under conditions of physiological hydration
- Urine tests for urogenital infection (chlamydia, mycoplasma, ureaplasma)
- Virological examination (HSV, CMV, Epstein-Barr virus)
- Urine culture for fungal and anaerobic infections

List of additional diagnostic measures:

Special research methods carried out when the process subsides or during the period of clinical and laboratory remission (according to indications)
- rhythm and volume of spontaneous urination, taking into account the liquid drunk
- urodynamic study
- test with furosemide and water load
- excretory urography (not performed with reduced GFR and creatinemia)
- voiding cystography
- urine analysis according to Zimnitsky
- study of titratable acidity
- urine osmolarity
- microalbumin, β2-microglobulin, α1-microglobulin in urine
- fermenturia (LDH, GGT, alkaline phosphatase, etc.)
- dynamic renoscintigraphy
- static renoscintigraphy (not earlier than 6 months after the relief of clinical and laboratory signs of pyelonephritis)

Diagnostic criteria

Complaints and anamnesis:
- chills, fever 38°C;
- general weakness, malaise, refusal to eat
- there may be pain in the lumbar region
- symptoms of dysuria and edema may appear.

Physical examination:
- body temperature is subfebrile or normal
- positive Pasternatsky syndrome on palpation

Laboratory research
- increase in ESR 20 mm/hour;
- increase in CRP 10-20 mg/l;
- increase in serum PCT 2 ng/ml.

Instrumental studies
- Ultrasound of the kidneys: congenital malformations, cysts, stones
- Cystography - vesicoureteral reflux or condition after antireflux surgery
- Nephroscintigraphy - lesions of the renal parenchyma
- For tubulointerstitial nephritis - diagnostic puncture biopsy of the kidney (with parental consent)

Indications for consultation with specialists:
Consultation with a urologist, pediatric gynecologist
According to indications, consultation with an andrologist, ophthalmologist, otolaryngologist, phthisiatrician, clinical immunologist, dentist, neurologist

Differential diagnosis

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Treatment

Treatment goals:

Elimination of the infectious process

Elimination of predisposing factors

Restoration of urodynamics and renal function

Nephroprotective therapy for progressive nephropathy

Recovery and prevention of complications.

Treatment tactics:

Non-drug treatment

Regimen: bed rest for the entire period of fever, then general.

Diet No. 7:

By age, balanced in basic nutrients, without protein restrictions;
- limitation of extractives, spices, marinades, smoked meats, products with a pungent taste (garlic, onions, cilantro) and products containing excess sodium;
- drink plenty of fluids (50% more than the age norm) with alternating slightly alkaline mineral waters.

Compliance with the regime of “regular” urination (every 2-3 hours - depending on age);

Daily hygiene measures (shower, bath, wiping, thorough toilet of the external genitalia);

Drug treatment

- Symptomatic therapy: antipyretic, detoxification, infusion - usually carried out in the first 1-3 days;

- Antibacterial therapy in 3 stages:

- Stage 1 - antibiotic therapy - 10-14 days;

Empirical (starting) choice of antibiotics:

- “Protected” penicillins: amoxicillin/clavulanate, amoxicillin/sulbactam;

III generation cephalosporins: cefotaxime, ceftazidime, ceftriaxone, cefixime, ceftibuten.

Severe:

Aminoglycosides: netromycin, amikacin, gentamicin;

Carbapenems: imipenem, meropenem;

IV generation cephalosporins (cefepime).

Indications for parenteral therapy.

Age<3 месяцев;

Severe condition of the child: severe activity of the infectious-inflammatory process or clinical suspicion of sepsis, severe intoxication or dehydration;

Dyspeptic symptoms (vomiting) and malabsorption in the gastrointestinal tract;

Inability to take medications orally;

Resistance to empirical oral antibiotics.

Clinical criteria for switching to oral administration:

Clinical improvement and absence of fever within 24 hours;

No vomiting and ensuring compliance.

- Severe course (fever ≥39°C, dehydration, repeated vomiting): IV antibiotics until the temperature normalizes (on average 2-3 days), followed by switching to oral administration (step therapy) for up to 10-14 days;

- Mild course (moderate fever, no significant dehydration, sufficient fluid intake): oral antibiotics for at least 10 days. A single intravenous injection is possible in case of questionable compliance.

When treatment is effective, the following are observed:

Clinical improvement within 24-48 hours from the start of treatment;

Eradication of microflora after 24-48 hours;

Reduction or disappearance of leukocyturia 2-3 days from the start of treatment.

Changing the antibacterial drug if it is ineffective after 48-72 hours should be based on the results of a microbiological study and the sensitivity of the isolated pathogen to antibiotics.

Dosage regimen of antimicrobial drugs in children with pyelonephritis (L.S. Strachunsky, Yu.B. Belousov, S.N. Kozlov, 2007)

Probiotics

Surgery - no

Prevention

Preventive measures - no specific prevention

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. List of references 1. Urinary tract infection in children: diagnosis, treatment and long-term management. NICE guideline. - London (UK): National Institute for Health and Clinical Excellence, 2007. - 30 p. 2. Pyelonephritis in young children: modern approaches to diagnosis and treatment. A.I. Safina. Nephrology, PM Pediatrics. Lectures for practicing doctors, Practical Medicine 07, 2012 3. Practical guide to anti-infective chemotherapy, edited by: L.S. Strachunsky, Yu.B. Belousova, S.N. Kozlova, 2010 4. Clinical pharmacology edited by Academician of the Russian Academy of Medical Sciences, prof. V.G. Kukesa, 2008, 5. Thomas B. Newman. The New American Academy of Pediatrics Urinary Tract Infection Guideline // Pediatrics. - 2011. - Vol. 128. - P. 572 6. Vozianov A.F., Maydannik V.G., Bidny V.G., Bagdasarova I.V. Fundamentals of childhood nephrology. Kyiv: Book Plus, 2002. pp. 22–100. 7. Malkoch A.V., Kovalenko A.A. Pyelonephritis//In the book. “Childhood Nephrology” / ed. V. A. Tabolina et al.: a practical guide to childhood diseases (edited by V. F. Kokolina, A. G. Rumyantsev). M.: Medpraktika, 2005. T. 6. P. 250–282.

Information

List of protocol developers
Kalieva M.M. - Candidate of Medical Sciences, Associate Professor of the Department of Clinical Pharmacology, Exercise Therapy and Physiotherapy Kazakh. National Medical University named after S.D. Asfendiyarov,
Mubarakshinova D.E. - Assistant of the Department of Clinical Pharmacology, Exercise Therapy and Physiotherapy Kazakh. National Medical University named after S.D. Asfendiyarov

Reviewers:
Toleutaev E.T. - Doctor of Medical Sciences, Head of the Children's Somatic Department of JSC "NSCMD"

Conditions for reviewing the protocol: after 3 years from the date of publication

Attached files

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