Diagnosis and treatment of polycystic kidney complicated by pyelonephritis
In people with the same morphological changes in the kidneys, polycystic disease occurs in two clinical and radiologic forms - symptomatic, rapidly progressive, and asymptomatic, progressing slowly. Those suffering from the second form of the disease live 15-20 years longer than patients with the first form. This is due to adherence to polycystosis pyelonephritis, suppuration of cysts, hemorrhages in the cysts, a violation of urodynamics in patients with the first form.
Urinary tract infection complicates polycystic kidney disease relatively often. Researchers have detected pyelonephritis in 40% of children and in 84% of adults with polycystic disease.
The development of pyelonephritis and the maintenance of the inflammatory process is facilitated by structural and functional disorders of the kidneys, which under conditions of urostasis impart a stable course to pyelonephritis. With each exacerbation, new parenchyma sites are affected and the kidney function is reduced. Due to the development of acute pyelonephritis against the background of already developed chronic renal failure, the polycystic disease becomes extremely unfavorable and the prognosis worsens.
Disturbance of venous outflow from the kidneys is considered one of the main links in the pathogenesis of chronic pyelonephritis in patients with polycystosis. Quickly growing in the area of the gates of the kidney cysts lead to intraorganic phlebostasis.
Diagnosis of polycystosis presents certain difficulties due to the polymorphism of the manifestations and the lack or incorrect evaluation of the data of objective examination of patients. It is especially difficult to diagnose polycystosis in children. Often sick children enter hospitals with a diagnosis of pyelonephritis or glomerulonephritis. In some patients, polycystosis is detected when already enlarged, bumpy kidneys are palpated and complications occur: hypertension, chronic pyelonephritis, renal failure.
For the diagnosis of polycystic disease, general clinical and radiological studies have traditionally been used, according to which 82% of patients can be diagnosed. Preference is given to the results of X-ray studies: excretory urography, retrograde pyelography, angiography.
On retrograde pyelograms, one can ascertain the renal cavity system. But this study is conducted rarely because of the danger of developing an ascending infection.
On angiograms, polycystic kidneys form avascular zones, the main vessels are thinned and elongated and the number of small arteries is insignificant. With sufficiently high information content, this study is traumatic. On angiograms, it is impossible to detect cysts with a diameter less than 2 cm.
In recent years, ultrasound echography has been increasingly used in hospitals for diagnostic purposes. According to this informative and nontraumatic study in combination with the data of traditional studies, it is possible to diagnose all suffering from polycystic kidney disease.
For this purpose, patients were examined for real-time machines Aloka-SSD 110C( Japan) and Brüel and Kjær( Denmark) with prefixes for sectoral scanning and photography.
On echograms obtained by longitudinal scanning, the normal kidney is a bean-shaped form, its respiratory mobility is noted. Kidney contours are relatively well differentiated from surrounding tissues. Children and thin people can detect the cortical layer of the kidney. They have the same medullary substance of the kidney on the echogram has a very delicate, heterogeneous structure. This must be taken into account, so as not to take the normal medulla of the kidney for its cystic lesion. The calyx is revealed in the center, their image is layered on the image of the kidney vessels and fatty tissue in the kidney gates. If there are some liquids in the cups, they take the form of centrally located echo-negative cylindrical structures. With transverse scanning, the calyx well differentiates from the medulla of the kidney. These are small( normally up to 0.5 cm), clearly outlined echo-negative formations of the oval form. At some people in the field of a gate of a kidney it is possible to distinguish a pelvis.
Polycystic is characterized by an increase in the kidneys, the unevenness of their contours, the echo-negative rounded zones in the parenchyma. Echograms reveal cysts with a diameter of up to 0.3 cm. Smaller cysts create a scalloped edge of the cups. In patients with large cysts, occupying the entire parenchyma, the boundaries of the kidneys are clearly distinguishable, the cavity system is not determined. With the development of concomitant pyelonephritis, the number of echoes increases in the preserved parenchyma, the cyst walls are sclerotized, thickened. If the cysts are inflamed, the content loses homogeneity, echopositive inclusions of various sizes appear in it.
The results of ultrasound can be used to detect polycystic kidney disease in children whose parents are polycystic.
To this end, we examined 19 adults with polycystic kidney disease( 15 women and 4 men), and 30 of their children aged 2 to 21 years. At the time of the initial examination only polycystic kidney polycystosis was detected in 27 children( 90%).Meanwhile, only 10 children presented complaints of headaches, weakness, frequent catarrhal diseases. Of these, 2 had palpated enlarged kidneys. In 6, changes in the composition of urine( proteinuria and leukocyturia) were determined. Arterial blood pressure exceeded the age norms in 8 children.
Thus, only a third of patients had symptoms of urological disease, the rest of the polycystosis was asymptomatic.
It follows from the foregoing that, according to ultrasound data, it is possible to diagnose, outline treatment tactics and monitor the condition of the kidneys of patients with polycystosis.
From August 1984 to October 1985, the clinic produced 26 percutaneous punctures in patients with polycystic kidney disease. Three patients were cysted with right kidney cysts, 14 patients had cysts of the left kidney and 6 had cysts of both kidneys. In 1 patient the puncture of the cysts failed because of the severe sclerosis of the parenchyma surrounding them. The contents of the cysts were purulent in 4 patients, in the remaining patients - light yellow.5 patients 1-3 days after the operation noted hematuria, spontaneously ceased. With dynamic echographic observation, hematomas in the kidney region were not detected in any operated one.2 patients with combined polycystic liver and kidney damage were punctured with liver brushes.
Patients with polycystic kidney complicated by pyelonephritis were treated conservatively and promptly.
Over the past 10 years, the clinic has treated 116 patients with polycystic disease.79.4% of them are conservative because they had small renal cysts in two phases of the intermittent stage with chronic renal failure and mainly the secretory form of the terminal stage of chronic renal failure without septic complications of polycystosis.
Exacerbation of chronic pyelonephritis, suppuration of cysts, increased pain syndrome and deterioration of renal hemodynamics in the phase of exacerbation of the intermittent stage of chronic renal failure served as an indication for surgical treatment.14 patients underwent a needle-puncture and subsequently antibacterial and treatment. The kidney function improved in 9 of them, did not change in 2, progressed kidney failure in 3. Postoperative hemodialysis was needed by 2 patients, as a result, both improved kidney function.
6 patients with terminal stage of chronic renal failure due to the development of acute purulent pyelonephritis kidney was removed. As a result of the elimination of the septic focus and the source of toxicosis, the excretory function of the remaining kidney improved in 3 patients.
Exacerbation of pyelonephritis, suppuration of cysts may occur during treatment of patients with programmed hemodialysis. Of the 33 patients who underwent hemodialysis, 5 had cysts in their cysts, and they had to perform a nephrectomy. In the majority of patients, due to prolonged treatment with hemodialysis, the cysts decreased, the intensity of the kidneys decreased and their sizes decreased.
Thus, polycystic kidney complicated by pyelonephritis should be diagnosed in a timely and complex manner, using ultrasound echography besides traditional methods. Active treatment of patients with polycystic kidney with septic complications can be carried out in the early and later stages of chronic renal failure.
Women's magazine www. BlackPantera.en: VR Ivanovich