One of the most common kidney diseases is pyelonephritis. The pathogenesis of this process is associated with inflammatory and degenerative changes in the tissues of the organ. With inadequate treatment, this disease leads to the formation of multiple abscesses. So, what is this pathological process, what are the causes of pyelonephritis, pathogenesis and treatment of this disease? Let's try to consider in this article.
What is this disease
It refers to non-specific infectious and inflammatory pathologies, during which the pyelocaliceal system is affected, as well as the interstitial tissue of the kidney parenchyma. Pyelonephritis is one of the most commonly diagnosed diseases of the genitourinary system in men, women and children. However, according to WHO statistics, young and middle-aged women are most susceptible to this disease. They suffer from the symptoms of pyelonephritis (the pathogenesis of which is more often infectious) almost five times more often than men.
Modernmedicine divides this disease into primary (non-obstructive) or secondary (obstructive, developing against the background of urinary outflow disorders due to inflammation of the tissues and their compression) pyelonephritis. At the same time, acute and chronic forms are distinguished according to the clinical course of infectious and inflammatory pathology.
Etiology and pathogenesis of pyelonephritis
This pathological phenomenon can be triggered by any endogenous or exogenous microorganisms that have penetrated into the renal tissue. These are usually Gram-negative bacteria. The most common pathogenesis with a clinic of pyelonephritis caused by Escherichia coli (more than 50% of cases). With prolonged treatment of the disease with the use of antibiotic therapy regimens, the addition of a candidal infection is possible.
Pathogens can enter kidney tissue in three ways:
- In the presence of foci of inflammation in the internal organs, pathogenic microflora can penetrate into the kidneys through the circulatory system (hematogenous route). This is one of the most common ways to infect the pelvic organs in general.
- In the presence of vesicoureteropelvic reflux (reverse flow of urine due to some physiological processes), an infection called ascending (urinogenic) can occur.
- The causes of the pathogenesis of pyelonephritis can be infection ascending through the subepithelial spaces of the ureter wall.
The phenomena of ascending urinogenic processes are possible only if there is infected urine in the bladder,entering through the ureter, first into the pyelocaliceal system, and then into the kidney parenchyma. This process is possible only in the presence of fornic (damage to the calyx vault) or tubular (reverse reflux of urine from the renal pelvis into the parenchyma, more precisely into the tubules of the kidney) variety of reflux.
In the process of ascending urinogenous infection, hematogenous infection may also be attached. This happens when, due to pyelovenous or pyelolymphatic reflux, microbes penetrate into the tissues of the kidney.
The pathogenesis of acute pyelonephritis can be triggered by local changes in the kidneys and upper urinary tract. Usually, such phenomena are associated with a violation of the passage of urine, for example, due to the destruction of the stone, structural features of the ureter and other reasons. The source of pyelonephritis may be a violation of the outflow of urine caused by phimosis or inflammation of the prostate gland. The etiology and pathogenesis of chronic pyelonephritis in this case are accompanied by hemodynamic changes in the interstitial tissue, which contributes to the creation of optimal conditions for the vital activity of pathogenic microorganisms.
The general condition of the body has a huge impact on the dynamics of the development of the disease. Factors that have a negative impact on the condition of the kidneys are:
- poor or unbalanced diet;
- lack of vitamins and vital trace elements;
- dehydration;
- hypothermia;
- frequent somatic diseases;
- physical overload;
- diseasesendocrine and cardiovascular systems, as well as liver disease.
Such conditions reduce the body's resistance and make it susceptible to any infections.
Stages of the disease: causes and symptoms
The pathogenesis of pyelonephritis is determined by the stage of development of the disease, the presence of complications, as well as a combination of clinical manifestations of the infectious process and local symptoms. The stages of development of this disease correspond to the morphological changes occurring in the kidney.
The initial stage of the disease is a serious process, the duration of which varies from 6 to 36 hours. Against the background of the secondary pathogenesis of pyelonephritis in children and adults, accompanied by a general weakness of the body and ailments, symptoms such as:
- fever with a further increase in body temperature to 40 ⁰С and above;
- sometimes colic followed by chills;
- increased perspiration;
- headaches, nausea, occasional vomiting;
- in rare cases, patients report diarrhea, dry mouth and tachycardia attacks.
After lowering the temperature, the state of he alth improves. However, the apparent relief is an imaginary state. If the prerequisites for violations in the body are not eliminated, then a few hours after such an attack, severe pain in the lumbar region will again appear, and the attack will repeat.
In non-obstructive (primary) pyelonephritis, local symptoms may be absent.
Forsubsequent stages of the disease are characterized by purulent, destructive changes that occur in the following sequence:
- Apostematous pyelonephritis, in which small (1-2 mm) multiple pustules appear on the surface and in the cortex of the kidney.
- Carbuncle of an organ, resulting either from the fusion of purulent formations in apostematous pyelonephritis, or as a result of a microbial embolus entering the final arterial vessel of the organ, which is manifested by a combination of ischemic, necrotic and purulent-inflammatory process.
- Kidney abscess occurs as a result of purulent fusion of tissues. The contents of a burst abscess can penetrate into the paraumbilical tissue, resulting in the development of purulent paranephritis or even phlegmon of the retroperitoneal space (inflammation that does not have clear boundaries).
- Purulent paranephritis.
With such processes, pain in the lumbar region passes by attacks. In such a case of the pathogenesis of acute pyelonephritis, the painful organ can be felt, as there is muscle tension from the affected kidney.
As the body becomes intoxicated, the patient experiences dehydration and pallor of the skin.
What happens in the body during the acute course of the disease
In the diagnosis and treatment of acute pyelonephritis (the clinic of etiology and pathogenesis of which is manifested in the appearance of a large number of pustules caused by infections), there is a worsening of the course of this inflammatory disease. However, byIn the opinion of many clinicians, in determining the true culprit of a patient's poor he alth, there are often some difficulties leading to diagnostic errors.
In the acute course of the disease, the kidney undergoes some changes: it becomes larger, and its fibrous dense cover (capsule) thickens. When it is opened, the bean-shaped organ bleeds and, as a rule, phenomena of perinephritis are observed. The section of the affected kidney shows wedge-shaped yellowish areas, and microscopic examination of the interstitial tissue reveals multiple perivascular infiltrates with a tendency to form abscesses.
Infection present in the interstitial tissue penetrates into the lumen of the tubules. Many small, millet-like painful foci (a characteristic feature of apostematous nephritis) form in the renal glomeruli. At the same time, due to the presence and circulation in the blood or lymph of a pathogenic agent, pustules appear around the tubules of the kidney.
In addition, in the pathogenesis of acute pyelonephritis, there is the formation of pustules and purulent gray-yellow stripes in the medulla of the kidney, extending up to the papillae. On closer examination, the accumulation of leukocytes is found both in the direct tubules and in the surrounding tissues. Disturbances in the blood supply in the papillae can cause necrosis and lead to the pathogenesis of chronic pyelonephritis, while numerous small abscesses (apostemes) can merge and form one abscess.
Pathological changes in acute formspyelonephritis often occur against the background of the appearance of numerous pustules located over the entire area of the affected organ. Nevertheless, the highest concentration of apostems is found either in the cortical layer, or in any one zone of the kidney, where they are concentrated into a carbuncle.
When several apostemes merge or melt the carbuncle in acute pathogenesis of pyelonephritis, the diagnosis, carried out using laboratory and instrumental studies, determines the abscess of the kidney. When blood supply is disturbed due to inflammatory edema or vascular thrombosis, necrotic papillitis occurs.
The acute course of this disease can occur at any age, regardless of gender and ethnicity of the patient, however, non-obstructive (primary) processes are most often observed in the pathogenesis of pyelonephritis in children and women under 40.
For the clinical manifestations of this disease in the acute course is characterized by a combination of general and local symptoms. Common features include:
- fever and severe chills;
- excessive sweating;
- changes in the composition of the blood;
- blood pressure jumps;
- signs of intoxication.
Local manifestations are like:
- lower back pain (provoked on examination or spontaneous);
- muscle tone in the hypochondrium and lower back;
- change in color and composition of urine;
- increased and sometimes painful urination.
Symptoms of acuteforms of inflammation
Complete diagnosis and treatment of clinical pathogenesis and etiology of acute pyelonephritis are often vital steps for the patient. The main manifestations of this pathological process are, first of all, a sharp increase in body temperature to 39-40 ° C, the appearance of weakness, chills, headaches, increased sweating and the main signs of intoxication (dizziness, nausea, vomiting, sometimes diarrhea). At the same time, pain in the lower back appears, localized, as a rule, on one side. The pain syndrome may be dull, aching or acute.
Often the mechanism of origin and development of pyelonephritis (pathogenesis) is preceded by urolithiasis. In this case, before the onset of an immediate attack of this disease, acute renal colic is observed, but without impaired urination.
Sometimes, at the initial stages of the development of the pathogenesis of pyelonephritis in women, men and children, there are signs of a serious infectious process without local manifestations. In the first hours of the onset of the disease, severe chills are usually observed, accompanied by febrile conditions with high fever, headache and aches throughout the body. With a decrease in temperature, imaginary relief comes, however, the patient has rapid breathing and dry mouth.
In the process of manifestation of the general symptoms of pyelonephritis, local signs are gradually added: pains of varying intensity in the lower back, groin area or upper abdomen. The appearance of increased pain is typical for casesthe transition of inflammation to the capsule of the kidney or perirenal tissue. Periodic temperature rises usually indicate the development of numerous pustular foci in the organ.
A few days after the onset of infectious etiology and pathogenesis of pyelonephritis in children and adults, the pain syndrome is localized in the area of the affected organ. At the same time, at night, there is an increase in pain, especially in the supine position. Unpleasant sensations may be aggravated by taking deep breaths or coughing.
During examination, palpation shows pain, accompanied by muscle tone in the back and abdomen. Severe pain is observed when pressing with fingers at certain points:
- from the side of the back at the level of the intersection of the lower ribs with the long lumbar muscles;
- from the side of the abdomen at the so-called upper ureteral point, located three fingers to the left or right of the navel.
Often, patients experience scoliosis in the direction of the affected kidney.
Chronic pyelonephritis: symptoms
As a rule, the etiology and pathogenesis of chronic pyelonephritis are the consequences of an undercooked disease that proceeded in an acute form. This happens in cases where the inflammatory process in the kidney was removed, but the causative agent of the disease remained. Chronic pyelonephritis also occurs in situations where it was not possible to normalize the outflow of urine from the organ.
The disease can constantly bother with dull aching pains in the lumbar region, especially in the autumn-spring period. ExceptMoreover, the disease can periodically worsen, and then the patient experiences all the signs of an acute course of this pathology.
Modern medicine distinguishes between local and local symptoms of chronic pyelonephritis. Local symptoms include recurrent mild pain in the lumbar region, usually unilateral. They rarely appear during active movement and are more often observed at rest.
In the primary course of the pathogenesis of chronic pyelonephritis, the pain syndrome never takes on the character of renal colic and does not affect other areas. In patients with a secondary form of the disease, the symptoms are more pronounced, since they are complications of a number of diseases that lead to a violation of the outflow of urine from the kidneys. These can be urolithiasis, benign growths of the prostate gland, uterine fibroids, kidney prolapse and other pathologies.
In a significant number of patients, especially in the treatment of the pathogenesis of pyelonephritis in women, the inflammatory process occurs against the background of long-term therapy for chronic cystitis with frequent exacerbations. Therefore, patients with chronic pyelonephritis often report urination disorders associated with inflammation of the bladder.
General symptoms of chronic pyelonephritis are divided into early and late.
Early symptoms are typical for patients with unilateral or bilateral pyelonephritis, not accompanied by impaired renal function. In this case, there is:
- fatigue;
- intermittent weakness;
- loss of appetite;
- subfebrile body temperature.
The culprit of these manifestations is venous congestion in the kidneys, while most people experience an increase in blood pressure.
Late symptoms include things like:
- dry mouth;
- adrenal discomfort;
- heartburn and belching;
- psychological passivity;
- appearance of puffiness;
- pallor and dry skin.
Such symptoms may serve as some manifestations of chronic renal failure. Therefore, the treatment and prevention of the clinic of the pathogenesis of chronic pyelonephritis is a necessary condition for the normal functioning of the patient.
When Pregnant
According to medical statistics, various inflammatory pathologies of the kidneys occur in about 10% of pregnant women. The fact is that in all systems and organs of the female body during this period there are numerous changes. So, under the action of the hormone that supports pregnancy (progesterone), the smooth muscles of the ureters, bladder and urethra relax. Often this allows the pathogenic environment to enter the urinary tract.
In addition, the growing fetus during pregnancy puts significant pressure on the kidneys and bladder, which leads to impaired blood circulation in the tissues of these organs and contributes to urinary retention. Often this becomes a predetermining factor in the occurrencepathogenesis of pyelonephritis in pregnant women. It is worth adding here the weakening of the protective functions of the immune system, since the main forces of the female body during this period are thrown to ensure the normal course of pregnancy.
Problems in diagnosing pyelonephritis
Recently, there has been a tendency towards a latent course of this disease. This significantly complicates the diagnosis of pyelonephritis, not only in chronic, but also in acute form. Therefore, the disease is accidentally detected only during examination for other diseases or already in the later stages of pathogenesis. The etiology of pyelonephritis in children and adults can drag on for years.
When diagnosing this pathological process, remember that:
- Pyelonephritis is much more common in young women.
- In boys and men, this pathology occurs much less frequently than in older people, who often have infravesical obstruction due to inflammation of prostate adenoma.
- Pyelonephritis is predisposed to people with obstructive uropathy, vesicoureteral reflux (VUR), polycystic kidney disease (which may occur without a urinary infection), or immunocompromised states (diabetes mellitus, tuberculosis).
You can identify signs of pyelonephritis in the process of careful history taking. So, for example, one of the common signs of the disease - chills, can regularly appear for a long time, not only in the cold, but also in the heat.
Another early sign of illness can be nocturia,noted for several years and not associated with the use of large amounts of liquid. Although this is not a symptom specific to pyelonephritis, nocturia may indicate a decrease in the concentration function of the kidneys.
Laboratory diagnosis of disease
Prognosis of the pathogenesis of pyelonephritis can only be given by a qualified specialist after studying the results of a number of laboratory and instrumental analyzes and tests.
Laboratory studies
Clinical urinalysis is one of the main diagnostic steps. Pyelonephritis is characterized by an increase in the number of leukocytes, but the data obtained should always be compared with the patient's complaints and medical history. For example, asymptomatic manifestations of leukocyturia in women (up to 60 or more leukocytes) require the exclusion of gynecological pathologies. And with a combination of minimal leukocyturia with an increase in body temperature, it is necessary to be guided by the data of anamnestic, clinical, laboratory and instrumental examinations.
In the prevention and prognosis of the pathogenesis of pyelonephritis, urine pH deserves special attention. Normally, in the presence of a urinary infection, the acid reaction can change to sharply alkaline. However, it can also occur, for example, with uremia or pregnancy.
Urine culture: theoretically, this method can give an idea of the pathogen and help choose adequate treatment regimens. However, in real practice this does not always happen, so rely onresults obtained using this method cannot be obtained.
Instrumental diagnostics
This technique usually involves the use of ultrasound, X-ray, radionuclide equipment.
During chromocystoscopy and excretory urography, signs of primary acute pyelonephritis are expressed by a decrease in the function of the affected kidney, as well as a slowdown in the excretion of colored or concentrated urine from the affected areas. With the help of excretory urograms in the early stages of the onset of chronic pyelonephritis, hypertension and hyperkinesia of the calyces can be detected, which in the later stages of the disease are replaced by hypotension.
Using ultrasound (ultrasound) during the development of pyelonephritis, it is possible to detect the expansion of the renal pelvis, coarsening of the contours of the cups, heterogeneity of the structure of the parenchyma with areas of its scarring, as well as the mobility of the kidneys. This is the most popular method for determining pathological processes in an organ.
This technique also allows you to detect signs of delayed manifestations of the disease. Among them, deformation and change in the size of the kidney or a change in the thickness of the parenchyma can be noted. However, these indicators may indicate the development of other nephropathies. In addition, ultrasound examinations of the kidneys make it possible to identify pathologies associated with pyelonephritis: urolithiasis, obstructive uropathy, vesicoureteral reflux (VUR), polycystic kidney disease and other conditions that precede the onset of a purulent-inflammatory process.
Identifythe position, outline of the kidneys and the presence of stones in the urinary system can be obtained using survey urography techniques.
Computed tomography is also often used to diagnose pyelonephritis, but this technique does not provide any particular advantages over ultrasound, therefore it is mainly used to determine tumor processes. In this case, SCT and MSCT are considered the most informative methods for studying kidney disease, providing a three-dimensional reconstruction of the organ image and virtual endoscopy with detailing the size and structural density of neoplasms.
Radionuclide methods for diagnosing pyelonephritis allow you to identify the functioning parenchyma, delimiting areas of scarring, which allows you to predict the pathogenesis of the disease.
X-ray examination
The use of X-ray techniques allows you to visualize the urinary tract and identify signs of obstructive uropathy and urinary streaks. This method is used to detect chronic pyelonephritis by detecting coarsening and deformities of the contours of the kidney, thinning of the parenchyma, dilatation and hypotension of the pelvis, flattening of the papillae and narrowing of the necks of the cups
Treatment and prognosis
Uncomplicated form of acute pyelonephritis can be treated with conservative methods in a hospital setting. For the fastest relief of the inflammatory process and reducing the risk of the transition of the pathological process into a purulent-destructive form, various schemes are used.antibiotic therapy. In the acute course of the disease, detoxification therapy is mandatory and immunity is adjusted.
In the initial stages of treatment of secondary pyelonephritis in acute form, it is necessary to restore the normal outflow of urine. For this, catheterization of the ureter is most often performed, and in advanced cases, pyelo- or nephrostomy is applied.
In case of febrile syndromes, a diet with a low intake of protein foods is prescribed. After stabilization of the body temperature, the patient is transferred to a full-fledged diet with a high fluid content.
Treatment of chronic pyelonephritis follows the same schemes as the treatment of an acute pathological process, but here the recovery period is longer and more laborious. Therapeutic measures in this case should include:
- identification and elimination of factors that could provoke difficulty in the outflow of urine or led to impaired renal blood flow;
- taking antibiotics;
- correction of immunity.
Treatment and prevention of the pathogenesis of chronic pyelonephritis requires long-term systematic therapy and a full recovery process. Treatment started in the hospital should be continued on an outpatient basis. As additional methods, some recipes of traditional medicine and herbal medicine can be used, however, it is necessary to decide on the appropriateness of their use with the attending specialist. Patients suffering from manifestations of this pathological process, during the period of remission of the diseaseit is recommended to undergo spa treatment.
