Chronic pyelonephritis of the kidneys - symptoms, diagnosis, treatment. Signs and treatment of chronic pyelonephritis Chronic pyelonephritis in remission

Chronic pyelonephritis is a kidney disease that threatens the general condition of the body. What is chronic pyelonephritis and how it can be dangerous - read our article.

Causes of chronic pyelonephritis

Most often, chronic pyelonephritis is a consequence of improper treatment of diseases of the genitourinary system (cystitis, urethritis, acute pyelonephritis or urolithiasis disease). However, doctors identify other causes of chronic pyelonephritis:

• Hormonal disruptions and gynecological diseases in women;
• Decreased immunity;
• promiscuity;
• Stress and emotional stress;
• hypothermia;
• Diabetes.

The disease may be caused different types bacteria:

• coli;
• Enterococci;
• Proteus;
• Staphylococci;
• Streptococci.

All of them have varying degrees of resistance to antibiotics, therefore, in order to prescribe adequate treatment, it is important to correctly determine the etiology of the disease. Regardless of the causes, the chronic form is always preceded by an acute attack. Chronicity of the disease causes untimely outflow of urine. It can be caused by urolithiasis, a peculiar structure of the ureter, nephroptosis and prostate adenoma. Diseases that are not related to the genitourinary system can also support inflammation in the body:

• Cholecystitis;
• Appendicitis;
• Enterocolitis;
• Tonsillitis;
• Otitis;
• sinusitis etc.

Reduced immunity, obesity and intoxication of the body contribute to the development of infection.

Incorrectly prescribed therapy threatens the patient with an increase in the recovery period and the development of complications. Reliable identification of the etiological factor is the key to successful treatment and recovery of the patient.

Classification of chronic pyelonephritis

According to the WHO classification, there are many forms of this disease. According to the activity of the infection, chronic pyelonephritis is divided into three phases:

1. Phase of active inflammation;
2. Phase of latent inflammation;
3. remission phase.

Each of the phases has differences in both the symptoms and the results of the studies. Adequate treatment contributes to the transition of the acute period into the latent one. The latent period is expressed very weakly, almost imperceptibly. The patient may be disturbed by general fatigue, subfebrile body temperature and headaches. There may not be any symptoms specifically indicating a disease of the urogenital area. After several months, the latent disease is replaced by recovery (remission) or a new attack. In the acute stage, it is already possible to clearly distinguish the symptoms inherent in pyelonephritis. Urine culture in this period also indicates pathology. Bacteria and leukocytes (bacteriuria and leukocyturia), as well as protein up to 3 g / l (proteinuria) are excreted in the urine.

According to the occurrence, two forms of chronic pyelonephritis are divided:

1. Primary - not associated with previous diseases of the urological sphere. During the study of the pathology of this form, doctors usually do not find factors that could contribute to the retention of bacteria in the tissues of the kidney.
2. Secondary - if there were previously lesions of the urinary tract. For example, the calculous form develops against the background of urolithiasis.

Depending on the localization of pyelonephritis, its forms are distinguished:

• left hand;
• Right hand;
• Bilateral.

Symptoms

Symptoms of pyelonephritis will vary depending on the stage of pathogenesis (development of the disease), as well as in different categories of patients (men, women or children). Suspicions of chronic pyelonephritis in doctors arise already with the following signs:

• Increased body temperature;
• Pain in the lumbar region;
• Dysuria;
• Headaches and general malaise;
• Increased fatigue;
• The presence of edema and bags under the eyes.

It should be noted that the symptoms in the acute phase are more pronounced and require immediate treatment. The feeling of pain becomes unbearable. An exacerbation symptom such as heat, can reach a critical point (up to 41 C).

The latent period of pyelonephritis is characterized by sluggish symptoms. Most often they are indirect and do not belong either to patients or doctors to a disease of a urological nature. So, a consequence of chronic pyelonephritis can be high blood pressure (hypertension). The work of the kidneys and the cardiovascular system are closely related. If the condition of the kidneys worsens, a hypertensive crisis occurs. Raise blood pressure quite often observed in patients with diseased kidneys (about 40%).

Symptoms of pyelonephritis in women do not differ from the general clinical picture. However, if in parallel the patient suffers from cystitis or another urological disease, the symptoms become mixed, making it difficult to accurately diagnose and treat. In men, the symptoms of pyelonephritis may be signs of other urological or andrological diseases. Therefore, it is important to contact a specialist in a timely manner. Manifestations of pyelonephritis can be even in infants and infants. In children, pyelonephritis most often has obvious symptoms. A feature of the course of pyelonephritis in children is a very rapid intoxication due to a rise in temperature. At home, you can help the baby with symptomatic methods of treatment:

• Bed rest;
• Anesthesia;
• Decrease in body temperature.

Diagnostics

Chronic pyelonephritis is most easily diagnosed in a hospital setting. To make a diagnosis, an experienced nephrologist usually only needs to prescribe a standard examination. Diagnosis of chronic pyelonephritis includes:

• Blood and urine tests;
• Ultrasound examination of the kidneys;
• Analysis of smears in women (if gynecological diseases are suspected).

The results of the tests will help the doctor determine the nature of the disease (etiopathogenesis). The main criteria by which the disease is determined through tests are leukocyturia, bacteriuria and proteinuria. An increase in the number of leukocytes is not always associated with a severe course of the disease. Therefore, the test data is always compared with the patient's complaints and the overall clinical picture. Ultrasound will show possible diffuse changes kidneys. To more accurately formulate the diagnosis, the doctor may prescribe additional tests. It is not uncommon for a disease to be diagnosed by chance during an examination for another disease.

Treatment

Chronic pyelonephritis is treated comprehensively. Antibiotics and uroseptics are used. The doctor may also prescribe herbal medicines. The successful outcome of treatment largely depends on preliminary urine culture with the determination of sensitivity to drugs. Thus, the doctor determines which antibiotics should be used to treat the disease in each individual case. Most often, pyelonephritis in the acute stage can be cured with the following medications:

• Penicillins (amoxicillin, carbenicillin, azlocillin);
• Cephalosporins;
• Fluoroquinolones (levofloxacin, ciprofloxacin, ofloxacin, norfloxacin).

Nitrofurans (furadonin, furagin, furamag) cope well with pyelonephritis, but have many side effects (nausea, vomiting, bitterness in the mouth). Sulfanilamide (biseptol) and oxyquinoline drugs (nitroxoline) are well tolerated by humans, but bacteria have also recently become less sensitive to them. Treatment can be administered both in tablet form and in injections.

In the treatment of pyelonephritis, the most important thing is to adhere to the indicated treatment regimen. The drug must be taken exactly as many days as the doctor wrote. Otherwise, the therapy will not cope with the bacteria completely, and after a while they will begin to attack the body again. Successful treatment of an exacerbation leads to the transition of the disease into remission.

Treatment in remission is reduced to preventive measures:

• Diet;
• Drinking mode;
• The alternation of oxidizing and alkalizing foods in the diet;
• Herbal teas;
• Strengthening immunity;
• Moderate physical activity;
• Spa treatment.

The latter, by the way, is one of the most effective ways to maintain the patient's quality of life at the proper level. The main factor in choosing a sanatorium for kidney treatment is the availability of mineral waters. With the help of the healing properties of water from the kidneys are excreted harmful substances, inflammatory processes are eliminated. The medical standard of modern resorts involves a nursing process. This is A complex approach to the treatment of patients, including the provision of professional medical care and patient care. Quality nursing care is also practiced in modern clinics.

If you follow all the doctor's clinical recommendations, the prognosis for chronic pyelonephritis can be quite favorable. The disease can be cured completely, forever forgetting about its unpleasant symptoms. In this case, the patient may even be removed from the register if he has previously been observed by a doctor. Ignoring medical prescriptions can have serious consequences for the patient. Pyelonephritis not cured in time is dangerous with numerous complications (carbuncle or kidney abscess, sepsis). They can cause disability or bacteriotoxic shock, which is fatal. Bilateral pyelonephritis leads to liver damage (hepatorenal syndrome).

Therefore, despite the fact that the disease is in remission, take good care of your health. Do not self-medicate, take tests on time and visit a specialized doctor. He will tell you how to properly treat pyelonephritis.

The unique remedy ASD-2 helps in the treatment of kidney diseases. The main active ingredient of the drug is folic acid. Under its influence, the process of reabsorption takes place faster in the renal tubules. the right substances. In addition, ASD-2 helps to restore the adaptive capabilities of the body, normalizing Ph-balance and increasing resistance to pathogenic factors (physical, emotional overload and stress). At the stage of remission, this is an excellent remedy, thanks to which the disease can completely pass.

Diet

Diet is the basis of the treatment of chronic pyelonephritis. Patients who have suffered acute pyelonephritis are shown the "Table 7" diet. The basis of the diet of a patient with pyelonephritis should include natural products steamed or boiled. Salt intake should be reduced to a minimum. It is better to replace purified tap water with mineral water.

What you can eat:

• Low-fat varieties of poultry, meat and fish;
• 1 egg per day;
• Yesterday's bread
• Pasta from durum wheat;
• Cereals;
• Fruits and vegetables;
• Fruit drinks (especially cranberry).;
• Weak black and green tea;
• Vegetable and butter oils.

What not to eat:

• Strong broths from fatty meats;
• mushrooms;
• Spicy and fatty foods;
• fried foods;
• Chocolate, confectionery;
• Strong coffee;
• legumes;
• Fresh bread and buns.

Eating on this therapeutic diet is not so difficult. Enough to get used to natural taste products. Thematic books with dietary recipes will help to diversify medical nutrition.

Prevention

Prevention of chronic pyelonephritis includes timely treatment of the acute phase of the disease. To prevent acute pyelonephritis, you need not to overcool and eliminate foci of infections in the body in time. It is very important to strengthen the immune system from the inside with vitamins, proper balanced nutrition and hardening procedures. Once a year or more often, be sure to take blood and urine tests.

During pregnancy

Chronic pyelonephritis and pregnancy is a fairly common occurrence. The reason for this is the growth of the fetus, due to which the kidneys are displaced. There is a violation of the outflow of urine, bacteria are not excreted from the body on time - inflammation occurs. Pregnancy itself with chronic pyelonephritis can proceed quite normally. However, the condition of the expectant mother at the same time leaves much to be desired. Complicating the situation is that antibiotic therapy is contraindicated during pregnancy. After passing all the necessary tests and confirming the diagnosis, the attending physician prescribes the most appropriate drugs with minimal risk to the child. Many mothers are concerned about the question of whether it is possible to give birth if this ailment was discovered during pregnancy. Doctors say that timely detection of pathology and control over it allows women to give birth on their own in 95% of cases.

Do they take to the army with chronic pyelonephritis

Conscripts with chronic pyelonephritis may not serve in the army. However, there are many nuances here. For diagnosis, leukocyturia and bacteriuria must be observed in the urine for 12 months. It is known that in the stage of remission, these indicators can be reduced. Therefore, to make the most accurate diagnosis, the commission is appointed several times.

Okorokov A. N.
Treatment of diseases of internal organs:
Practical guide. Volume 2
Minsk - 1997.

Treatment of chronic pyelonephritis

Chronic pyelonephritis- a chronic non-specific infectious and inflammatory process with a primary and initial lesion of the interstitial tissue, pelvicalyceal system and renal tubules, followed by involvement of the glomeruli and renal vessels.

Treatment program for chronic pyelonephritis.
1.
2.
3. (restoration of urine outflow and anti-infective therapy).
4.
5.
6.
7. .
8.
9.
10.
11.
12. .
13. Treatment of chronic renal failure (CRF).

1.Mode

The patient's regimen is determined by the severity of the condition, the phase of the disease (exacerbation or remission), clinical features, the presence or absence of intoxication, complications of chronic pyelonephritis, the degree of CRF.

Indications for hospitalization of the patient are:

• pronounced exacerbation of the disease;
• development of hard-to-correct arterial hypertension;
• progression of chronic renal failure;
• violation of urodynamics, requiring the restoration of the passage of urine;
• clarification functional state kidneys;
• o development of an expert solution.

In any phase of the disease, patients should not be subjected to cooling, and significant physical exertion is also excluded.
With a latent course of chronic pyelonephritis with a normal level of blood pressure or mild arterial hypertension, as well as with preserved kidney function, regimen restrictions are not required.
With exacerbations of the disease, the regimen is limited, and patients with a high degree of activity and fever are prescribed bed rest. Access to the dining room and toilet is allowed. In patients with high arterial hypertension, renal insufficiency, it is advisable to limit motor activity.
As the exacerbation is eliminated, the symptoms of intoxication disappear, blood pressure normalizes, the symptoms of CRF decrease or disappear, the patient's regimen expands.
The entire period of treatment of exacerbation of chronic pyelonephritis until the full expansion of the regime takes about 4-6 weeks (S. I. Ryabov, 1982).

In chronic pyelonephritis, it is advisable to prescribe predominantly acidifying food (bread, flour products, meat, eggs) for 2-3 days, then an alkalizing diet (vegetables, fruits, milk) for 2-3 days. This changes the pH of the urine, the interstitium of the kidneys and creates an unfavorable environment for microorganisms.

3. Etiological treatment

Etiological treatment includes the elimination of the causes that caused the violation of the passage of urine or renal circulation, especially venous, as well as anti-infective therapy.

Restoration of urine outflow is achieved by the use of surgical interventions (removal of prostate adenoma, stones from the kidneys and urinary tract, nephropexy in case of nephroptosis, plastic surgery of the urethra or ureteropelvic segment, etc.), i.e. restoration of the passage of urine is necessary for the so-called secondary pyelonephritis. Without a sufficiently restored urine passage, the use of anti-infective therapy does not give a stable and long-term remission of the disease.

Anti-infective therapy for chronic pyelonephritis is the most important measure both in the secondary and in the primary variant of the disease (not associated with a violation of the outflow of urine through the urinary tract). The choice of drugs is made taking into account the type of pathogen and its sensitivity to antibiotics, the effectiveness of previous courses of treatment, nephrotoxicity of drugs, the state of kidney function, the severity of CRF, the effect of urine reaction on the activity of drugs.

Chronic pyelonephritis is caused by a wide variety of flora. The most common causative agent is E. coli, in addition, the disease can be caused by enterococcus, Proteus vulgaris, staphylococcus, streptococcus, Pseudomonas aeruginosa, mycoplasma, less often - fungi, viruses.

Often chronic pyelonephritis is caused by microbial associations. In some cases, the disease is caused by L-forms of bacteria, i.e. transformed microorganisms with loss of the cell wall. The L-form is an adaptive form of microorganisms in response to chemotherapeutic agents. Shellless L-forms are inaccessible to the most commonly used antibacterial agents, but retain all toxic-allergic properties and are able to support the inflammatory process (but bacteria are not detected by conventional methods).

For the treatment of chronic pyelonephritis, various anti-infective drugs - uroantiseptics are used.

The main pathogens of pyelonephritis are sensitive to the following uroantiseptics.
E. coli: highly effective chloramphenicol, ampicillin, cephalosporins, carbenicillin, gentamicin, tetracyclines, nalidixic acid, nitrofuran compounds, sulfonamides, phosphacin, nolicin, palin.
Enterobacter: highly effective chloramphenicol, gentamicin, palin; tetracyclines, cephalosporins, nitrofurans, nalidixic acid are moderately effective.
Proteus: ampicillin, gentamicin, carbenicillin, nolicin, palin are highly effective; moderately effective levomycetin, cephalosporins, nalidixic acid, nitrofurans, sulfonamides.
Pseudomonas aeruginosa: highly effective gentamicin, carbenicillin.
Enterococcus: highly effective ampicillin; moderately effective carbenicillin, gentamicin, tetracyclines, nitrofurans.
Staphylococcus aureus (not forming penicillinase): penicillin, ampicillin, cephalosporins, gentamicin are highly effective; moderately effective carbenicillin, nitrofurans, sulfonamides.
Staphylococcus aureus (forming penicillinase): highly effective oxacillin, methicillin, cephalosporins, gentamicin; tetracyclines, nitrofurans are moderately effective.
Streptococcus: penicillin, carbenicillin, cephalosporins are highly effective; ampicillin, tetracyclines, gentamicin, sulfonamides, nitrofurans are moderately effective.
Mycoplasma infection: highly effective tetracyclines, erythromycin.

Active treatment with uroantiseptics should be started from the first days of exacerbation and continued until all signs of the inflammatory process are eliminated. After that, it is necessary to prescribe an anti-relapse course of treatment.

Basic rules for prescribing antibiotic therapy:
1. Correspondence of the antibacterial agent and the sensitivity of the microflora of urine to it.
2. The dosage of the drug should be made taking into account the state of kidney function, the degree of CRF.
3. The nephrotoxicity of antibiotics and other uroantiseptics should be taken into account and the least nephrotoxic ones should be prescribed.
4. If there is no therapeutic effect within 2-3 days from the start of treatment, the drug should be changed.
5. With a high degree of activity of the inflammatory process, severe intoxication, severe course of the disease, ineffectiveness of monotherapy, it is necessary to combine uroantiseptic agents.
6. It is necessary to strive to achieve a urine reaction that is most favorable for the action of an antibacterial agent.

In the treatment of chronic pyelonephritis, the following antibacterial agents are used: antibiotics ( tab. one), sulfa drugs, nitrofuran compounds, fluoroquinolones, nitroxoline, nevigramon, gramurin, palin.

3.1. Antibiotics

Table 1. Antibiotics for the treatment of chronic pyelonephritis

A drug	Daily dose
Penicillin group
Benzylpenicillin	Intramuscularly 500,000-1,000,000 IU every 4 hours
Methicillin
Oxacillin	Intramuscularly 1 g every 6 hours
Dicloxacillin	Intramuscularly, 0.5 g every 4 hours
Cloxacillin	Intramuscularly 1 g every 4-6 hours
Ampicillin	Intramuscularly 1 g every 6 hours, orally 0.5-1 g 4 times a day
Amoxicillin	Inside, 0.5 g every 8 hours
Augmentin (amoxicillin + clavulanate)	Intramuscularly 1.2 g 4 times a day
Unazine (ampicillin + sulbactam)	Inside 0.375-0.75 g 2 times a day, intramuscularly 1.5-3 g 3-4 times a day
Ampiox (ampicillin + oxacillin)	Inside 0.5-1 g 4 times a day, intramuscularly 0.5-2 g 4 times a day
Carbenicillin	Intramuscularly, intravenously, 1-2 g 4 times a day
Azlocillin	Intramuscularly 2 g every 6 hours or intravenous drip
Cephalosporins
Cefazolin (kefzol)	Intramuscularly, intravenously, 1-2 g every 8-12 hours
Cefalotin	Intramuscularly, intravenously, 0.5-2 g every 4-6 hours
Cefalexin
Cefuroxime (ketocef)	Intramuscularly, intravenously, 0.75-1.5 g 3 times a day
Cefuroxime-axetil	Inside, 0.25-0.5 g 2 times a day
Cefaclor (ceclor)	Inside, 0.25-0.5 g 3 times a day
Cefotaxime (claforane)	Intramuscularly, intravenously, 1-2 g 3 times a day
Ceftizoxime (epocelin)	Intramuscularly, intravenously, 1-4 g 2-3 times a day
Ceftazidime (fortum)	Intramuscularly, intravenously, 1-2 g 2-3 times a day
Cefobid (cefoperazone)	Intramuscularly, intravenously, 2-4 g 2-3 times a day
Ceftriaxone (Longacef)	Intramuscularly, intravenously, 0.5-1 g 1-2 times a day
Carbapenems
Imipinem + cilastatin (1:1)	Intravenous drip 0.5-1 g per 100 ml of 5% glucose solution or intramuscularly 0.5-0.75 g every 12 hours with lidocaine
Monobactams
Aztreonam (azaktam)	Intramuscularly, intravenously, 1-2 g every 6-8 hours or 0.5-1 g every 8-12 hours
Aminoglycosides
Gentamicin (Garamycin)
Tobramycin (Brulamycin)	Intramuscularly, intravenously, 3-5 mg / kg per day in 2-3 injections
Sizomycin	Intramuscularly, intravenously drip on 5% glucose solution
Amikacin	Intramuscularly, intravenously, 15 mg / kg per day in 2 injections
Tetracyclines
Metacycline (Rondomycin)	Inside, 0.3 g 2 times a day for 1-1.5 hours before meals
Doxycycline (Vibramycin)	Inside, intravenously (drip) 0.1 g 2 times a day
Lincosamines
Lincomycin (Lincocin)	Inside, intravenously, intramuscularly; inside 0.5 g 4 times a day; parenterally 0.6 g 2 times a day
Clindamycin (dalacin)	Inside, 0.15-0.45 g every 6 hours; intravenously, intramuscularly, 0.6 g every 6-8 hours
Levomycetin group
Chloramphenicol (levomycetin)	Inside, 0.5 g 4 times a day
Levomycetin succinate (chlorocide C)	Intramuscularly, intravenously, 0.5-1 g 3 times a day
Fosfomycin (phosphocin)	Inside, 0.5 g every 6 hours; intravenous stream, drip, 2-4 g every 6-8 hours

3.1.1. Preparations of the penicillin group
With an unknown etiology of chronic pyelonephritis (the causative agent has not been identified), it is better to choose penicillins with an extended spectrum of activity (ampicillin, amoxicillin) from the drugs of the penicillin group. These drugs actively affect the gram-negative flora, most gram-positive microorganisms, but staphylococci that produce penicillinase are not sensitive to them. In this case, they must be combined with oxacillin (ampiox) or use highly effective combinations of ampicillin with beta-lactamase (penicillinase) inhibitors: unazine (ampicillin + sulbactam) or augmentin (amoxicillin + clavulanate). Carbenicillin and azlocillin have pronounced antipseudomonal activity.

3.1.2. Preparations of the cephalosporin group
Cephalosporins are very active, have a powerful bactericidal effect, have a wide antimicrobial spectrum (actively affect gram-positive and gram-negative flora), but have little or no effect on enterococci. Only ceftazidime (fortum), cefoperazone (cefobid) have an active effect on Pseudomonas aeruginosa from cephalosporins.

3.1.3. Carbapenem preparations
Carbapenems have a wide spectrum of activity (gram-positive and gram-negative flora, including Pseudomonas aeruginosa and staphylococci that produce penicillinase - beta-lactamase).
In the treatment of pyelonephritis from the drugs of this group, imipinem is used, but always in combination with cilastatin, since cilastatin is a dehydropeptidase inhibitor and inhibits the renal inactivation of imipinem.
Imipinem is a reserve antibiotic and is prescribed for severe infections caused by multiple resistant strains of microorganisms, as well as for mixed infections.

3.1.4. Monobactam preparations
Monobactams (monocyclic beta-lactams) have a powerful bactericidal effect against gram-negative flora and high resistance to the action of penicillinases (beta-lactamases). This group of drugs includes aztreonam (azaktam).

3.1.5. Aminoglycoside preparations
Aminoglycosides have a powerful and faster bactericidal effect than beta-lactam antibiotics, have a wide antimicrobial spectrum (gram-positive, gram-negative flora, Pseudomonas aeruginosa). It should be remembered about the possible nephrotoxic effect of aminoglycosides.

3.1.6. Lincosamine preparations
Lincosamines (lincomycin, clindamycin) have a bacteriostatic effect, have a fairly narrow spectrum of activity (gram-positive cocci - streptococci, staphylococci, including those producing penicillinase; non-spore-forming anaerobes). Lincosamines are not active against enterococci and gram-negative flora. To lincosamines, resistance of microflora, especially staphylococci, is rapidly developing. In severe chronic pyelonephritis, lincosamines should be combined with aminoglycosides (gentamicin) or with other antibiotics that act on gram-negative bacteria.

3.1.7. Levomycetin
Levomycetin is a bacteriostatic antibiotic, active against gram-positive, gram-negative, aerobic, anaerobic bacteria, mycoplasmas, chlamydia. Pseudomonas aeruginosa is resistant to chloramphenicol.

3.1.8. Fosfomycin
Fosfomycin is a bactericidal antibiotic with a wide spectrum of action (acts on gram-positive and gram-negative microorganisms, and is also effective against pathogens resistant to other antibiotics). The drug is excreted unchanged in the urine, therefore it is very effective in pyelonephritis and is even considered a reserve drug for this disease.

3.1.9. Accounting for the reaction of urine
When prescribing antibiotics for pyelonephritis, the reaction of urine should be taken into account.
With an acidic reaction of urine, the action of the following antibiotics is enhanced:
- penicillin and its semi-synthetic preparations;
- tetracyclines;
- novobiocin.
With an alkaline urine reaction, the action of the following antibiotics is enhanced:
- erythromycin;
- oleandomycin;
- lincomycin, dalacin;
- aminoglycosides.
Drugs whose action does not depend on the reaction of the environment:
- chloramphenicol;
- ristomycin;
- vancomycin.

3.2. Sulfonamides

Sulfonamides in the treatment of patients with chronic pyelonephritis are used less frequently than antibiotics. They have bacteriostatic properties, act on gram-positive and gram-negative cocci, gram-negative "rods" (E. coli), chlamydia. However, enterococci, Pseudomonas aeruginosa, anaerobes are not sensitive to sulfonamides. The action of sulfonamides increases with alkaline urine.

Urosulfan - is prescribed 1 g 4-6 times a day, while a high concentration of the drug is created in the urine.

Combined preparations of sulfonamides with trimethoprim are characterized by synergism, a pronounced bactericidal effect and a wide spectrum of activity (gram-positive flora - streptococci, staphylococci, including penicillinase-producing ones; gram-negative flora - bacteria, chlamydia, mycoplasmas). The drugs do not act on Pseudomonas aeruginosa and anaerobes.
Bactrim (biseptol) - a combination of 5 parts of sulfamethoxazole and 1 part of trimethoprim. It is prescribed orally in tablets of 0.48 g, 5-6 mg / kg per day (in 2 divided doses); intravenously in ampoules of 5 ml (0.4 g of sulfamethoxazole and 0.08 g of trimethoprim) in isotonic sodium chloride solution 2 times a day.
Groseptol (0.4 g of sulfamerazole and 0.08 g of trimethoprim in 1 tablet) is administered orally 2 times a day at an average dose of 5-6 mg / kg per day.
Lidaprim is a combination drug containing sulfametrol and trimethoprim.

These sulfonamides dissolve well in the urine, almost do not precipitate in the form of crystals in the urinary tract, but it is still advisable to drink soda water with each dose of the drug. It is also necessary during treatment to control the number of leukocytes in the blood, since leukopenia may develop.

3.3. Quinolones

Quinolones are based on 4-quinolone and are classified into two generations:
I generation:
- nalidixic acid (nevigramon);
- oxolinic acid (gramurine);
- pipemidic acid (palin).
II generation (fluoroquinolones):
- ciprofloxacin (cyprobay);
- ofloxacin (tarivid);
- pefloxacin (abaktal);
- norfloxacin (nolicin);
- Lomefloxacin (Maxaquin);
- enoxacin (penetrex).

3.3.1. I generation of quinolones
Nalidixic acid (Negramon, Negro) - the drug is effective in urinary tract infections caused by gram-negative bacteria, except for Pseudomonas aeruginosa. It is ineffective against gram-positive bacteria (staphylococcus, streptococcus) and anaerobes. It acts bacteriostatically and bactericidal. When taking the drug inside, a high concentration of it in the urine is created.
With alkalization of urine, the antimicrobial effect of nalidixic acid increases.
It is produced in capsules and tablets of 0.5 g each. It is prescribed orally 1-2 tablets 4 times a day for at least 7 days. With long-term treatment, 0.5 g is used 4 times a day.
Possible side effects of the drug: nausea, vomiting, headache, dizziness, allergic reactions (dermatitis, fever, eosinophilia), increased skin sensitivity to sunlight (photodermatosis).
Contraindications to the use of Nevigramone: impaired liver function, renal failure.
Nalidixic acid should not be administered simultaneously with nitrofurans, as this reduces the antibacterial effect.

Oxolinic acid (gramurin) - according to the antimicrobial spectrum, gramurin is close to nalidixic acid, it is effective against gram-negative bacteria (E. coli, Proteus), Staphylococcus aureus.
Available in tablets of 0.25 g. 2 tablets are prescribed 3 times a day after meals for at least 7-10 days (up to 2-4 weeks).
Side effects are the same as in the treatment of nevigramon.

Pipemidic acid (palin) - effective against gram-negative flora, as well as pseudomonas, staphylococci.
It is produced in capsules of 0.2 g and tablets of 0.4 g. It is prescribed at 0.4 g 2 times a day for 10 or more days.
Tolerability of the drug is good, sometimes there are nausea, allergic skin reactions.

3.3.2. II generation quinolones (fluoroquinolones)
Fluoroquinolones - new class synthetic broad-spectrum antibacterial agents. Fluoroquinolones have a wide spectrum of action, they are active against gram-negative flora (E. coli, enterobacter, Pseudomonas aeruginosa), gram-positive bacteria (staphylococcus, streptococcus), legionella, mycoplasma. However, enterococci, chlamydia, and most anaerobes are insensitive to them. Fluoroquinolones penetrate well into various organs and tissues: lungs, kidneys, bones, prostate, have a long half-life, so they can be used 1-2 times a day.
Side effects (allergic reactions, dyspeptic disorders, dysbacteriosis, agitation) are quite rare.

Ciprofloxacin (cyprobay) is the "gold standard" among fluoroquinolones, as it surpasses many antibiotics in terms of antimicrobial activity.
Available in tablets of 0.25 and 0.5 g and in vials with an infusion solution containing 0.2 g of cyprobay. It is prescribed orally, regardless of food intake, 0.25-0.5 g 2 times a day, with a very severe exacerbation of pyelonephritis, the drug is first administered intravenously, 0.2 g 2 times a day, and then oral administration is continued.

Ofloxacin (tarivid) - is available in tablets of 0.1 and 0.2 g and in vials for intravenous administration of 0.2 g.
Most often, ofloxacin is prescribed at 0.2 g 2 times a day orally, for very severe infections, the drug is first administered intravenously at a dose of 0.2 g 2 times a day, then switched to oral administration.

Pefloxacin (abactal) - is available in 0.4 g tablets and 5 ml ampoules containing 400 mg of abactal. It is prescribed orally at 0.2 g 2 times a day with meals, in severe condition, 400 mg is injected intravenously in 250 ml of a 5% glucose solution (abaktal cannot be dissolved in saline solutions) in the morning and evening, and then they switch to oral administration.

Norfloxacin (nolicin) - is available in tablets of 0.4 g, administered orally at 0.2-0.4 g 2 times a day, for acute urinary tract infections for 7-10 days, for chronic and recurrent infections - up to 3 months.

Lomefloxacin (maxakvin) - is available in tablets of 0.4 g, is administered orally at 400 mg 1 time per day for 7-10 days, in severe cases it can be used for a longer time (up to 2-3 months).

Enoxacin (penetrex) - is available in tablets of 0.2 and 0.4 g, is administered orally at 0.2-0.4 g 2 times a day, cannot be combined with NSAIDs (convulsions may occur).

Due to the fact that fluoroquinolones have a pronounced effect on the pathogens of urinary infections, they are considered as the drug of choice in the treatment of chronic pyelonephritis. For uncomplicated urinary infections, a three-day course of treatment with fluoroquinolones is considered sufficient, for complicated urinary infections, treatment is continued for 7-10 days, and for chronic urinary tract infections, longer use (3-4 weeks) is possible.

It has been established that it is possible to combine fluoroquinolones with bactericidal antibiotics - antipseudomonal penicillins (carbenicillin, azlocillin), ceftazidime and imipenem. These combinations are prescribed when bacterial strains resistant to fluoroquinolone monotherapy appear.
The low activity of fluoroquinolones against pneumococcus and anaerobes should be emphasized.

3.4. Nitrofuran compounds

Nitrofuran compounds have a wide spectrum of activity (gram-positive cocci - streptococci, staphylococci; gram-negative rods - Escherichia coli, Proteus, Klebsiella, Enterobacter). Anaerobes, Pseudomonas are insensitive to nitrofuran compounds.
During treatment, nitrofuran compounds may have undesirable side effects: dyspeptic disorders;
hepatotoxicity; neurotoxicity (damage to the central and peripheral nervous system), especially in renal failure and long-term treatment (more than 1.5 months).
Contraindications to the appointment of nitrofuran compounds: severe liver pathology, renal failure, diseases of the nervous system.
The most commonly used in the treatment of chronic pyelonephritis are the following nitrofuran compounds.

Furadonin - available in tablets of 0.1 g; well absorbed in the gastrointestinal tract, creates low concentrations in the blood, high - in the urine. It is prescribed orally at 0.1-0.15 g 3-4 times a day during or after meals. The duration of the course of treatment is 5-8 days, if there is no effect during this period, it is not advisable to continue treatment. The effect of furadonin is enhanced by acidic urine and weakened by urine pH > 8.
The drug is recommended for chronic pyelonephritis, but is inappropriate for acute pyelonephritis, as it does not create a high concentration in the kidney tissue.

Furagin - compared with furadonin, it is better absorbed in the gastrointestinal tract, better tolerated, but its concentration in the urine is lower. Available in tablets and capsules of 0.05 g and in powder form in jars of 100 g.
It is applied orally at 0.15-0.2 g 3 times a day. The duration of the course of treatment is 7-10 days. If necessary, the course of treatment is repeated after 10-15 days.
In severe exacerbation of chronic pyelonephritis, soluble furagin or solafur can be administered intravenously (300-500 ml of a 0.1% solution during the day).

Nitrofuran compounds are well combined with antibiotics aminoglycosides, cephalosporins, but are not combined with penicillins and chloramphenicol.

3.5. Quinolines (8-hydroxyquinoline derivatives)

Nitroxoline (5-NOC) - is available in tablets of 0.05 g. It has a wide spectrum of antibacterial action, i.e. affects gram-negative and gram-positive flora, is rapidly absorbed in the gastrointestinal tract, excreted unchanged by the kidneys and creates a high concentration in the urine.
It is prescribed orally 2 tablets 4 times a day for at least 2-3 weeks. In resistant cases, 3-4 tablets are prescribed 4 times a day. As needed, it can be used for a long time in courses of 2 weeks per month.
The toxicity of the drug is insignificant, side effects are possible; gastrointestinal disorders, skin rashes. When treated with 5-NOC, urine becomes saffron yellow.

When treating patients with chronic pyelonephritis, one should take into account the nephrotoxicity of drugs and give preference to the least nephrotoxic drugs - penicillin and semi-synthetic penicillins, carbenicillin, cephalosporins, chloramphenicol, erythromycin. The most nephrotoxic group of aminoglycosides.

If it is impossible to determine the causative agent of chronic pyelonephritis or until the antibiogram data are obtained, broad-spectrum antibacterial drugs should be prescribed: ampiox, carbenicillin, cephalosporins, quinolones nitroxoline.

With the development of CRF, the doses of uroantiseptics are reduced, and the intervals are increased (see "Treatment of chronic renal failure"). Aminoglycosides are not prescribed for CRF, nitrofuran compounds and nalidixic acid can be prescribed for CRF only in the latent and compensated stages.

Taking into account the need for dose adjustment in chronic renal failure, four groups of antibacterial agents can be distinguished:

• antibiotics, the use of which is possible in normal doses: dicloxacillin, erythromycin, chloramphenicol, oleandomycin;
• antibiotics, the dose of which is reduced by 30% with an increase in the urea content in the blood by more than 2.5 times compared to the norm: penicillin, ampicillin, oxacillin, methicillin; these drugs are not nephrotoxic, but in CRF they accumulate and give side effects;
• antibacterial drugs, the use of which in chronic renal failure requires mandatory adjustment of the dose and intervals of administration: gentamicin, carbenicillin, streptomycin, kanamycin, biseptol;
• antibacterial agents, the use of which is not recommended for severe chronic renal failure: tetracyclines (except doxycycline), nitrofurans, nevigramon.

Treatment with antibacterial agents for chronic pyelonephritis is carried out systematically and for a long time. The initial course of antibiotic treatment is 6-8 weeks, during which time it is necessary to achieve suppression of the infectious agent in the kidney. As a rule, during this period it is possible to achieve the elimination of clinical and laboratory manifestations of the activity of the inflammatory process. In severe cases of the inflammatory process, various combinations of antibacterial agents are used. An effective combination of penicillin and its semi-synthetic drugs. Nalidixic acid preparations can be combined with antibiotics (carbenicillin, aminoglycosides, cephalosporins). 5-NOC is combined with antibiotics. Bactericidal antibiotics (penicillins and cephalosporins, penicillins and aminoglycosides) are perfectly combined and mutually reinforce the action.

After the patient reaches the stage of remission, antibiotic treatment should be continued in intermittent courses. Repeated courses of antibiotic therapy in patients with chronic pyelonephritis should be prescribed 3-5 days before the expected appearance of signs of an exacerbation of the disease in order to maintain a remission phase for a long time. Repeated courses of antibacterial treatment are carried out for 8-10 days with drugs to which the sensitivity of the causative agent of the disease was previously detected, since there is no bacteriuria in the latent phase of inflammation and during remission.

Methods of anti-relapse courses in chronic pyelonephritis are described below.

A. Ya. Pytel recommends treating chronic pyelonephritis in two stages. During the first period, the treatment is carried out continuously with the replacement of the antibacterial drug with another every 7-10 days until the permanent disappearance of leukocyturia and bacteriuria occurs (for a period of at least 2 months). After that, intermittent treatment with antibacterial drugs for 15 days at intervals of 15-20 days is carried out for 4-5 months. With persistent long-term remission (after 3-6 months of treatment), you can not prescribe antibacterial agents. After that, anti-relapse treatment is carried out - sequential (3-4 times a year) course use of antibacterial agents, antiseptics, medicinal plants.

4. Use of NSAIDs

In recent years, the possibility of using NSAIDs in chronic pyelonephritis has been discussed. These drugs have an anti-inflammatory effect due to a decrease in the energy supply to the site of inflammation, reduce capillary permeability, stabilize lysosome membranes, cause a slight immunosuppressant effect, antipyretic and analgesic effect.
In addition, the use of NSAIDs is aimed at reducing the reactive phenomena caused by the infectious process, preventing proliferation, destroying fibrous barriers so that antibacterial drugs reach the inflammatory focus. However, it has been established that indomethacin with prolonged use can cause necrosis of the renal papillae and impaired hemodynamics of the kidney (Yu. A. Pytel).
Of the NSAIDs, the most appropriate is taking Voltaren (diclofenac sodium), which has a powerful anti-inflammatory effect and is the least toxic. Voltaren is prescribed 0.25 g 3-4 times a day after meals for 3-4 weeks.

5. Improved renal blood flow

Violation of renal blood flow plays an important role in the pathogenesis of chronic pyelonephritis. It has been established that in this disease there is an uneven distribution of renal blood flow, which is expressed in cortical hypoxia and phlebostasis in the medullary substance (Yu. A. Pytel, I. I. Zolotarev, 1974). In this regard, in the complex therapy of chronic pyelonephritis, it is necessary to use drugs that correct circulatory disorders in the kidney. For this purpose, the following means are used.

Trental (pentoxifylline) - increases the elasticity of erythrocytes, reduces platelet aggregation, enhances glomerular filtration, has a slight diuretic effect, increases oxygen delivery to the area of ​​ischemic tissues, as well as pulse blood filling of the kidney.
Trental is administered orally at 0.2-0.4 g 3 times a day after meals, after 1-2 weeks the dose is reduced to 0.1 g 3 times a day. The duration of the course of treatment is 3-4 weeks.

Curantil - reduces platelet aggregation, improves microcirculation, is prescribed 0.025 g 3-4 times a day for 3-4 weeks.

Venoruton (troxevasin) - reduces capillary permeability and edema, inhibits platelet and erythrocyte aggregation, reduces ischemic tissue damage, increases capillary blood flow and venous outflow from the kidney. Venoruton is a semi-synthetic derivative of rutin. The drug is available in capsules of 0.3 g and ampoules of 5 ml of a 10% solution.
Yu. A. Pytel and Yu. M. Esilevsky propose, in order to reduce the time of treatment of exacerbation of chronic pyelonephritis, to prescribe venoruton intravenously at a dose of 10-15 mg/kg for 5 days in addition to antibiotic therapy, then orally at 5 mg/kg 2 times a day. day during the entire course of treatment.

Heparin - reduces platelet aggregation, improves microcirculation, has anti-inflammatory and anti-complementary, immunosuppressant effects, inhibits the cytotoxic effect of T-lymphocytes, protects the vascular intima from the damaging effects of endotoxin in small doses.
In the absence of contraindications (hemorrhagic diathesis, gastric and duodenal ulcers), heparin can be prescribed against the background of complex therapy of chronic pyelonephritis, 5000 IU 2-3 times a day under the skin of the abdomen for 2-3 weeks, followed by a gradual dose reduction for 7-10 days until cancellation.

6. Functional passive kidney gymnastics

The essence of functional passive gymnastics of the kidneys is the periodic alternation of functional load (due to the appointment of a saluretic) and a state of relative rest. Saluretics, causing polyuria, contribute to the maximum mobilization of all reserve capabilities of the kidney by including in the activity a large number nephrons (under normal physiological conditions, only 50-85% of the glomeruli are in an active state). With functional passive gymnastics of the kidneys, not only diuresis is increased, but also renal blood flow. Due to the resulting hypovolemia, the concentration of antibacterial substances in the blood serum, in the renal tissue increases, and their effectiveness in the area of ​​inflammation increases.

As a means of functional passive gymnastics of the kidneys, lasix is ​​​​usually used (Yu. A. Pytel, I. I. Zolotarev, 1983). It is prescribed 2-3 times a week 20 mg of lasix intravenously or 40 mg of furosemide orally with the control of daily diuresis, electrolytes in the blood serum and blood biochemical parameters.

Negative reactions that can occur with passive kidney gymnastics:

• prolonged use of the method can lead to the depletion of the reserve capacity of the kidneys, which is manifested by a deterioration in their function;
• uncontrolled passive gymnastics of the kidneys can lead to a violation of the water and electrolyte balance;
• passive kidney gymnastics is contraindicated in violation of the passage of urine from the upper urinary tract.

7. Phytotherapy

In the complex therapy of chronic pyelonephritis, drugs are used that have anti-inflammatory, diuretic, and with the development of hematuria - a hemostatic effect ( tab. 2).

Table 2. Medicinal plants used in chronic pyelonephritis

plant name	Action
	diuretic	bactericidal	astringent	hemostatic
Altey Cowberry black elderberry Elecampane St. John's wort Corn silk Nettle angelica root birch leaves wheatgrass kidney tea Horsetail Chamomile Rowan bearberry cornflower flowers Cranberry strawberry leaf	- ++ ++ ++ + ++ - ++ ++ ++ +++ +++ - ++ +++ ++ + +	++ ++ + + +++ ++ ++ - - - - + ++ + ++ + + -	- - + - ++ + + - - - - + - + + - - -	- - - + + + +++ - - - - ++ - ++ - - - ++

Bearberry (bear ears) - contains arbutin, which is broken down in the body into hydroquinone (an antiseptic that has an antibacterial effect in the urinary tract) and glucose. It is used in the form of decoctions (30 g per 500 ml), 2 tablespoons 5-6 times a day. Bearberry acts in an alkaline environment, so the decoction should be combined with the ingestion of alkaline mineral waters ("Borjomi"), soda solutions. For alkalization of urine, apples, pears, raspberries are used.

Lingonberry leaves - have antimicrobial and diuretic effects. The latter is due to the presence of hydroquinone in lingonberry leaves. It is used as a decoction (2 tablespoons per 1.5 cups of water). Assigned to 2 tablespoons 5-6 times a day. Just like bearberry, it works better in an alkaline environment. Alkalinization of urine is performed in the same way as described above.

Cranberry juice, fruit drink (contains sodium benzoate) - has an antiseptic effect (the synthesis in the liver from hippuric acid benzoate increases, which, excreted in the urine, causes a bacteriostatic effect). Take 2-4 glasses a day.

In the treatment of chronic pyelonephritis, the following fees are recommended (E. A. Ladynina, R. S. Morozova, 1987).

Gathering #1

Gathering #2

Gathering #3

With exacerbation of chronic pyelonephritis, accompanied by an alkaline reaction, it is advisable to use the following collection:

Gathering #4

The following collection is recommended as maintenance antibiotic therapy:

Collection number 5

It is considered appropriate in chronic pyelonephritis to prescribe a combination of herbs as follows: one diuretic and two bactericidal for 10 days (for example, cornflower flowers - lingonberry leaves - bearberry leaves), and then two diuretics and one bactericidal (for example, cornflower flowers - birch leaves - leaves bearberry). Treatment medicinal plants takes a long time - for months and even years.
During the entire autumn season, it is desirable to eat watermelons due to their pronounced diuretic effect.

Along with taking the fees inside, baths with medicinal plants are useful:

Collection number 6(for Bath)

8. Increasing the overall reactivity of the body and immunomodulatory therapy

In order to increase the reactivity of the body and for the fastest relief of exacerbation, it is recommended:

• multivitamin complexes;
• adaptogens (tincture of ginseng, Chinese magnolia vine, 30-40 drops 3 times a day) during the entire period of exacerbation treatment;
• methyluracil 1 g 4 times a day for 15 days.

In recent years, a large role of autoimmune mechanisms in the development of chronic pyelonephritis has been established. Autoimmune reactions are promoted by deficiency of T-suppressor function of lymphocytes. Immunomodulators are used to eliminate immune disorders. They are prescribed for prolonged, poorly cured exacerbation of chronic pyelonephritis. The following drugs are used as immunomodulators.

Levamisole (decaris) - stimulates the function of phagocytosis, normalizes the function of T- and B-lymphocytes, increases the interferon-producing ability of T-lymphocytes. It is prescribed 150 mg once every 3 days for 2-3 weeks under the control of the number of leukocytes in the blood (there is a risk of leukopenia).

Timalin - normalizes the function of T- and B-lymphocytes, is administered intramuscularly at 10-20 mg 1 time per day for 5 days.

T-activin - the mechanism of action is the same, it is applied intramuscularly at 100 mcg once a day for 5-6 days.

Reducing the severity of autoimmune reactions, normalizing the functioning of the immune system, immunomodulators contribute to the rapid relief of exacerbations of chronic pyelonephritis and reduce the number of relapses. During treatment with immunomodulators, it is necessary to control the immune status.

9. Physiotherapy treatment

Physiotherapy treatment is used in the complex therapy of chronic pyelonephritis.
Physiotherapy techniques have the following effects:
- increase the blood filling of the kidney, increase the renal plasma flow, which improves the delivery of antibacterial agents to the kidneys;
- relieve spasm of smooth muscles of the renal pelvis and ureters, which contributes to the discharge of mucus, urinary crystals, bacteria.

The following physiotherapy procedures are applied.
1. Furadonin electrophoresis on the kidney area. The solution for electrophoresis contains: furadonin - 1 g, 1N NaOH solution - 2.5 g, distilled water - 100 ml. The drug moves from the cathode to the anode. The course of treatment consists of 8-10 procedures.
2. Electrophoresis of erythromycin on the kidney area. The solution for electrophoresis contains: erythromycin - 100,000 IU, ethyl alcohol 70% - 100 g. The drug moves from the anode to the cathode.
3. Electrophoresis of calcium chloride on the kidney area.
4. USV at a dose of 0.2-0.4 W/cm 2 in a pulsed mode for 10-15 minutes in the absence of urolithiasis.
5. Centimeter waves ("Luch-58") on the kidney area, 6-8 procedures per course of treatment.
6. Thermal procedures on the area of ​​the diseased kidney: diathermy, therapeutic mud, diathermo mud, ozocerite and paraffin applications.

10. Symptomatic treatment

With the development of arterial hypertension, antihypertensive drugs are prescribed (reserpine, adelfan, brinerdin, kristepin, dopegyt), with the development of anemia - iron-containing drugs, with severe intoxication - intravenous drip infusion of hemodez, neocompensan.

11. Spa treatment

The main spa factor in chronic pyelonephritis are mineral waters, which are used orally and in the form of mineral baths.

Mineral waters have an anti-inflammatory effect, improve renal plasma flow, glomerular filtration, have a diuretic effect, promote the excretion of salts, affect the pH of the urine (shift the urine reaction to the alkaline side).

Use the following resorts with mineral waters: Zheleznovodsk, Truskavets, Jermuk, Sairme, Berezovsky mineral waters, Slavyanovsky and Smirnovsky mineral springs.

Mineral water "Naftusya" of the Truskavets resort reduces spasm of the smooth muscles of the renal pelvis and ureters, which contributes to the discharge of small stones. In addition, it also has an anti-inflammatory effect.

"Smirnovskaya", "Slavyanovskaya" mineral waters are hydrocarbonate-sulfate-sodium-calcium, which is due to their anti-inflammatory effect.

Ingestion of mineral water helps to reduce inflammation in the kidneys and urinary tract, "wash out" of them mucus, microbes, small stones, "sand".

At the resorts, mineral water treatment is combined with physiotherapy.

Contraindications to spa treatment are:
- high arterial hypertension;
- severe anemia;
- HPN.

12. Planned anti-relapse treatment

The purpose of planned anti-relapse treatment is to prevent the development of relapse, exacerbation of chronic pyelonephritis. There is no single system of anti-relapse treatment.

O. L. Tiktinsky (1974) recommends the following method of anti-relapse treatment:
1st week - biseptol (1-2 tablets at night);
2nd week - herbal uroantiseptic;
3rd week - 2 tablets of 5-NOC at night;
4th week - chloramphenicol (1 tablet at night).
In subsequent months, maintaining the specified sequence, you can replace drugs with similar ones from the same group. In the absence of an exacerbation within 3 months, you can switch to herbal uroantiseptics for 2 weeks a month. A similar cycle is repeated, after which, in the absence of an exacerbation, interruptions in treatment lasting 1-2 weeks are possible.

There is another option for anti-relapse treatment:
1st week - cranberry juice, rosehip decoctions, multivitamins;
2nd and 3rd weeks - medicinal preparations (horsetail, juniper fruits, licorice root, birch leaves, bearberry, lingonberry, celandine grass);
4th week - an antibacterial drug, changing every month.

- This is a chronic nonspecific bacterial inflammation, occurring mainly with the involvement of the interstitial tissue of the kidneys and pyelocaliceal complexes. Manifested by malaise, dull pain in the lower back, subfebrile condition, dysuric symptoms. In the process of diagnosing, laboratory tests of urine and blood, ultrasound of the kidneys, retrograde pyelography, and scintigraphy are carried out. Treatment consists in following a diet and a sparing regimen, prescribing antimicrobial therapy, nitrofurans, vitamins, and physiotherapy.

ICD-10

N11 Chronic tubulointerstitial nephritis

General information

Causes

The etiological factor causing chronic pyelonephritis is the microbial flora. Mostly these are colibacillary bacteria (para-Escherichia and Escherichia coli), enterococci, Proteus, staphylococci, Pseudomonas aeruginosa, streptococci and their microbial associations. special role the development of the disease is played by L-forms of bacteria, which are formed as a result of ineffective antimicrobial therapy and changes in the pH of the environment. Such microorganisms are resistant to therapy, difficult to identify, able to persist in the interstitial tissue for a long time and become activated under the influence of certain conditions.

In most cases, chronic pyelonephritis is preceded by an acute attack. There are cases of a combination of pyelonephritis with chronic glomerulonephritis. Chronic inflammation is promoted by:

• unresolved urinary outflow disorders caused by kidney stones, ureteral stricture, vesicoureteral reflux, nephroptosis, prostate adenoma;
• other bacterial processes in the body (urethritis, prostatitis, cystitis, cholecystitis, appendicitis, enterocolitis, tonsillitis, otitis, sinusitis, etc.);
• common diseases ( diabetes, obesity), chronic immunodeficiency and intoxication.

In young women, the impetus for the development of chronic pyelonephritis may be the onset of sexual activity, pregnancy or childbirth. In children younger age the disease is often associated with congenital anomalies (ureterocele, bladder diverticula) that disrupt urodynamics.

Classification

Chronic pyelonephritis is characterized by three stages of inflammation in the kidney tissue.

1. At stage I, leukocyte infiltration of the interstitial tissue of the medulla and atrophy of the collecting ducts are detected; renal glomeruli are intact.
2. At stage II of the inflammatory process, cicatricial-sclerotic lesions of the interstitium and tubules are noted, which is accompanied by death. terminal departments nephrons and tubular compression. At the same time, hyalinization and desolation of the glomeruli, narrowing or obliteration of the vessels develop.
3. In the final, III stage, the renal tissue is replaced by scar tissue, the kidney has a reduced size, looks wrinkled with a bumpy surface.

According to the activity of inflammatory processes in the renal tissue in the development of chronic pyelonephritis, the phases of active inflammation, latent inflammation, remission (clinical recovery) are distinguished. Under the influence of treatment or in its absence, the active phase is replaced by a latent phase, which, in turn, can go into remission or again into active inflammation. The remission phase is characterized by the absence of clinical signs of the disease and changes in urine tests. According to clinical development, erased (latent), recurrent, hypertensive, anemic, and azotemichesky forms of pathology are distinguished.

Symptoms of chronic pyelonephritis

The latent form of the disease is characterized by poor clinical manifestations. Patients are usually worried about general malaise, fatigue, subfebrile condition, headache. Urinary syndrome (dysuria, back pain, edema), as a rule, is absent. Pasternatsky's symptom may be weakly positive. There is a slight proteinuria, intermittent leukocyturia, bacteriuria. Violation of the concentration function of the kidneys is manifested by hypostenuria and polyuria. Some patients may present with mild anemia and moderate hypertension.

The recurrent variant of chronic pyelonephritis proceeds in waves with periodic activation and subsidence of inflammation. The manifestations of this clinical form are heaviness and aching pain in the lower back, dysuric disorders, periodic feverish conditions. In the acute phase, a clinic of typical acute pyelonephritis develops. With progression, hypertensive or anemic syndrome may develop. Laboratory, especially during exacerbation, is determined by severe proteinuria, constant leukocyturia, cylindruria and bacteriuria, sometimes hematuria.

In the hypertensive form, the hypertensive syndrome becomes predominant. Arterial hypertension is accompanied by dizziness, headaches, hypertensive crises, sleep disturbances, shortness of breath, pain in the heart. Hypertension is often malignant. Urinary syndrome, as a rule, is not expressed or has an intermittent course. The anemic variant of the disease is characterized by the development of hypochromic anemia. Hypertension is not expressed, urinary - fickle and meager. Azotemic form combines cases when the disease is detected only at the stage of CRF. Clinical and laboratory findings of the azotemic form are similar to those of uremia.

Diagnostics

The difficulty of diagnosing chronic pyelonephritis is due to the variety of clinical variants of the disease and its possible latent course. Diagnostic tactics include:

• Urinalysis. AT general analysis urine revealed leukocyturia, proteinuria, cylindruria. The study of urine according to the method of Addis-Kakovsky is characterized by the predominance of leukocytes over other elements of the urinary sediment. Bacteriological culture of urine contributes to the detection of bacteriuria, identification of pathogens of chronic pyelonephritis and their sensitivity to antimicrobial drugs. To assess the functional state of the kidneys, Zimnitsky and Reberg tests, a biochemical study of blood and urine are used.
• General blood analysis. Hypochromic anemia, accelerated ESR, neutrophilic leukocytosis are found in the blood.
• Instrumental research. The degree of impaired renal function is specified using chromocystoscopy, excretory and retrograde urography, nephroscintigraphy. A decrease in the size of the kidneys and structural changes in the renal tissue are detected by ultrasound, MRI and CT of the kidneys. Instrumental methods objectively indicate a decrease in the size of the kidneys, deformation of the pelvicalyceal structures, and a decrease in the secretory function of the kidneys.
• Kidney biopsy. In clinically unclear cases of chronic pyelonephritis, a kidney biopsy is indicated. Meanwhile, sampling during a biopsy of unaffected renal tissue can give a false negative result in the morphological study of the biopsy.

In the process of differential diagnosis, kidney amyloidosis, chronic glomerulonephritis, hypertension, diabetic glomerulosclerosis are excluded.

Treatment of chronic pyelonephritis

Patients are shown compliance with a sparing regimen with the exclusion of factors provoking exacerbation (hypothermia, colds). Adequate therapy of all intercurrent diseases, periodic monitoring of urine tests, dynamic monitoring by a nephrologist are necessary.

Diet

Recommendations for the diet include the rejection of spicy foods, spices, coffee, alcoholic beverages, fish and meat broths. The diet should be fortified, containing dairy products, vegetable dishes, fruits, boiled fish and meat. It is necessary to consume at least 1.5-2 liters of fluid per day to prevent excessive concentration of urine and to ensure the washing of the urinary tract. With exacerbations of chronic pyelonephritis and with its hypertonic form, restrictions are imposed on the intake of table salt. Cranberry juice, watermelons, pumpkin, melons are useful.

Conservative therapy

An exacerbation requires the appointment of antibiotic therapy, taking into account the microbial flora (penicillins, cephalosporins, aminoglycosides, fluoroquinolones) in combination with nitrofurans (furazolidone, nitrofurantoin) or nalidixic acid preparations. Systemic chemotherapy is continued until bacteriuria ceases based on laboratory results.

In complex drug therapy, vitamins B, A, C are used; antihistamines (mebhydrolin, promethazine, chloropyramine). In the hypertensive form, antihypertensive and antispasmodic drugs are prescribed; with anemic - iron preparations, vitamin B12, folic acid.

Of the physiotherapeutic methods, SMT therapy, galvanization, electrophoresis, ultrasound, sodium chloride baths, etc. have proven themselves especially well. In the case of the development of uremia, hemodialysis is required.

Surgery

Far advanced chronic pyelonephritis, not amenable to conservative treatment and accompanied by unilateral wrinkling of the kidney, arterial hypertension, is the basis for nephrectomy.

Forecast and prevention

In a latent chronic variant of inflammation, patients long time retain their ability to work. In other forms, the ability to work is sharply reduced or lost. The timing of the development of chronic renal failure is variable and depends on the clinical variant of chronic pyelonephritis, the frequency of exacerbations, the degree of impaired renal function. The death of a patient can occur from uremia, acute disorders of cerebral circulation (hemorrhagic and ischemic stroke), heart failure.

Prevention consists in timely and active treatment of acute urinary infections (urethritis, cystitis, acute pyelonephritis), sanitation of foci of infection (chronic tonsillitis, sinusitis, cholecystitis, etc.); elimination of local disorders of urodynamics (removal of stones, dissection of strictures, etc.); immune correction.

Pyelonephritis is an inflammation of the kidneys that occurs in acute or chronic form. The disease is quite widespread and very dangerous to health. Symptoms of pyelonephritis include pain in the lumbar region, fever, severe general condition and chills. Occurs most often after hypothermia.

It can be primary, that is, it develops in healthy kidneys, or secondary, when the disease occurs against the background of already existing kidney diseases (glomerulonephritis, etc.). There are also acute and chronic pyelonephritis. Symptoms and treatment will directly depend on the form of the disease.

It is the most common kidney disease in all age groups. More often they suffer from young and middle-aged women - 6 times more often than men. In children, after diseases of the respiratory system (,) takes second place.

Causes of pyelonephritis

Why does pyelonephritis develop, and what is it? main reason pyelonephritis is an infection. Infection refers to bacteria such as E. coli, Proteus, Klebsiella, Staphylococcus and others. However, when these microbes enter the urinary system, the disease does not always develop.

In order for pyelonephritis to appear, contributing factors are also needed. These include:

1. Violation of the normal flow of urine (urine reflux from the bladder to the kidney, "neurogenic bladder", prostate adenoma);
2. Violation of the blood supply to the kidney (deposition of plaques in the vessels, vasospasm with, diabetic angiopathy, local cooling);
3. Immune suppression (treatment with steroid hormones (prednisolone), cytostatics, immunodeficiency as a result);
4. Contamination of the urethra (non-compliance with personal hygiene, with incontinence of feces, urine, during sexual intercourse);
5. Other factors (decrease in secretion of mucus in the urinary system, weakening of local immunity, impaired blood supply to the mucous membranes, urolithiasis, oncology, other diseases of this system and, in general, any chronic diseases, reduced fluid intake, abnormal anatomical structure of the kidneys).

Once in the kidney, microbes colonize the pyelocaliceal system, then the tubules, and from them - the interstitial tissue, causing inflammation in all these structures. Therefore, you should not postpone the question of how to treat pyelonephritis, otherwise severe complications are possible.

Symptoms of pyelonephritis

In acute pyelonephritis, the symptoms are pronounced - it begins with chills, when measuring body temperature, the thermometer shows over 38 degrees. After a while, aching pain in the lower back appears, the lower back "pulls", and the pain is quite intense.

The patient is disturbed by the frequent urge to urinate, very painful and indicating accession and. Symptoms of pyelonephritis may have general or local manifestations. General signs This:

• High intermittent fever;
• Severe chills;
• Sweating, dehydration and thirst;
• Intoxication of the body occurs, as a result of which the head hurts, fatigue increases;
• Dyspeptic symptoms (nausea, no appetite, stomach ache, diarrhea appears).

Local signs of pyelonephritis:

1. Pain in the lumbar region, on the affected side. The nature of the pain is dull, but constant, aggravated by palpation or movement;
2. The muscles of the abdominal wall may be tense, especially on the affected side.

Sometimes the disease begins with acute cystitis - rapid and, pain in the bladder area, terminal hematuria (appearance of blood at the end of urination). In addition, general weakness, weakness, muscle and headache, lack of appetite, nausea, vomiting.

If these symptoms of pyelonephritis appear, you should consult a doctor as soon as possible. In the absence of competent therapy, the disease can turn into a chronic form, which is much more difficult to cure.

Complications

• acute or chronic renal failure;
• various suppurative diseases of the kidneys (kidney carbuncle, kidney abscess, etc.);

Treatment of pyelonephritis

In primary acute pyelonephritis, in most cases, the treatment is conservative, the patient must be hospitalized in a hospital.

The main therapeutic measure is the impact on the causative agent of the disease with antibiotics and chemical antibacterial drugs in accordance with the data of the antibiogram, detoxification and immunity-enhancing therapy in the presence of immunodeficiency.

In acute pyelonephritis, treatment should begin with the most effective antibiotics and chemical antibacterial drugs, to which the microflora of the urine is sensitive, in order to eliminate the inflammatory process in the kidney as quickly as possible, preventing it from turning into a purulent-destructive form. In secondary acute pyelonephritis, treatment should begin with the restoration of urine massage from the kidney, which is fundamental.

Treatment of the chronic form is fundamentally the same as the acute form, but longer and more laborious. In chronic pyelonephritis, treatment should include the following main measures:

1. Elimination of the causes that caused the violation of the passage of urine or renal circulation, especially venous;
2. The appointment of antibacterial agents or chemotherapy drugs, taking into account the data of the antibiogram;
3. Increasing the immune reactivity of the body.

Restoration of the outflow of urine is achieved primarily by the use of one or another type surgical intervention(removal of prostate adenoma, stones from the kidneys and urinary tract, nephropexy with, plastic of the urethra or ureteropelvic segment, etc.). Often, after these surgical interventions, it is relatively easy to obtain a stable remission of the disease without long-term antibacterial treatment. Without a sufficiently restored urine massage, the use of antibacterial drugs usually does not give a long-term remission of the disease.

Antibiotics and chemical antibacterial drugs should be prescribed taking into account the sensitivity of the patient's urine microflora to antibacterial drugs. To obtain antibiogram data, antibacterial drugs with a wide spectrum of action are prescribed. Treatment for chronic pyelonephritis is systematic and long-term (at least 1 year). The initial continuous course of antibiotic treatment is 6–8 weeks, since during this time it is necessary to suppress the infectious agent in the kidney and resolve the purulent inflammatory process in it without complications in order to prevent the formation of scar connective tissue. In the presence of chronic renal failure, the appointment of nephrotoxic antibacterial drugs should be carried out under constant monitoring of their pharmacokinetics (concentration in the blood of urine). With a decrease in the indicators of humoral and cellular immunity, various drugs are used to increase immunity.

After the patient reaches the stage of remission of the disease, antibiotic treatment should be continued in intermittent courses. The timing of interruptions in antibacterial treatment is set depending on the degree of kidney damage and the time of onset of the first signs of an exacerbation of the disease, i.e., the onset of symptoms of the latent phase of the inflammatory process.

Antibiotics

Medicines are selected individually, taking into account the sensitivity of the microflora to them. The most commonly prescribed antibiotics for pyelonephritis are:

• penicillins with clavulanic acid;
• 2nd and 3rd generation cephalosporins;
• fluoroquinolones.

Aminoglycosides are undesirable because of their nephrotoxic effects.

How to treat pyelonephritis with folk remedies

Home treatment of pyelonephritis with folk remedies must necessarily be accompanied by bed rest and a healthy diet, consisting mainly of plant foods in raw, boiled or steam form.

1. During the period of exacerbation, such a collection helps. Mix equally taken white birch leaves, St. John's wort and knotweed grass, calendula flowers, fennel fruits (dill). Pour in a thermos 300 ml of boiling water 1 tbsp. l. collection, insist 1-1.5 hours, strain. Drink warm infusion in 3-4 doses 20 minutes before meals. The course is 3-5 weeks.
2. Outside of an exacerbation of the disease, use a different collection: knotweed herb - 3 parts; herb yasnotki (deaf nettle) and grass (straw) oats, leaves of sage officinalis and round-leaved wintergreen, rose hips and licorice roots - 2 parts each. Take 2 tbsp. l. collection, pour 0.5 l of boiling water in a thermos, leave for 2 hours and strain. Drink a third cup 4 times a day 15-20 minutes before meals. The course is 4-5 weeks, then a break for 7-10 days and repeat. In total - up to 5 courses (until stable results are obtained).

Diet

With inflammation of the kidneys, it is important to observe bed rest and a strict diet. Drink enough fluids to stop dehydration, which is especially important for pregnant women and people over 65.

With inflammatory processes in the kidneys, it is allowed: lean meat and fish, stale bread, vegetarian soups, vegetables, cereals, soft-boiled eggs, dairy products, sunflower oil. In small quantities, you can use onions, garlic, dill and parsley (dried), horseradish, fruits and berries, fruit and vegetable juices. Forbidden: meat and fish broths, smoked meats. You also need to reduce the consumption of spices and sweets.

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Chronic pyelonephritis is a disease that begins and spreads imperceptibly, without causing inconvenience to a person. Symptoms of the disease appear gradually.

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The site provides background information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious physician. All drugs have contraindications. You need to consult a specialist, as well as a detailed study of the instructions! .

The disease is a consequence of an untreated acute phase of pyelonephritis and lasts up to 15 years or more. Inflammatory process, affecting one kidney, often affects the second. The kidneys decrease in volume, their outer layer becomes loose and uneven.

In the future, in the absence of a response to the symptoms, the organs shrink, and necrosis of their tissues occurs. Chronic pyelonephritis can exist as an independent disease and another. According to statistics, women get sick more often than men, which is explained by a short urinary canal.

Symptoms and forms

The mechanism of occurrence of pyelonephritis is based on the reflux of urine affected by bacteria into the pelvis. Inflammation begins, moving from the walls of the pelvis to the medulla and cortex of the kidneys. The disease is characterized by sluggish symptoms or their complete absence.

In different patients, the picture of symptoms can vary significantly. This is due to the presence of one form or another of pyelonephritis.

In the latent form, there are no specific symptoms, but there are minor manifestations of the following signs:

• Fatigue,
• Dull pain in the side and lower back (Pasternatsky symptom),
• A slight rise in temperature
• Headache,
• General malaise.

Sometimes the clinic is characterized by a slight increase in pressure, mild anemia.

At this stage, the kidneys lose their ability to concentrate urine.

Urine analysis shows periodic sedimentation of leukocytes and bacteria.
The anemic form has already expressed symptoms:

• Tingling sensation in the region of the heart
• Dyspnea,
• pale skin,
• Marked weakness.

The hypertensive form is distinguished by arterial hypertension.
To the previous ailments are added:

• Dizziness,
• Insomnia,
• hypertensive crises,
• Stitching pains in the heart.

The azothermic form of pyelonephritis is a disease that manifests itself already with the onset of chronic renal failure. In fact, this is not a treated latent form.

Recurrent form - phases of relapse and remission, which replace each other depending on the conditions of the person's stay.
Symptoms of this form:

• Temperature increase,
• Chills,
• Discomfort in the lower back
• Frequent urge to go to the toilet
• Pain when urinating.

The period of exacerbation is acute pyelonephritis. With the development of a recurrent form, hypertensive or anemic syndrome often occurs.

According to the nature of inflammation, the disease is divided into phases:

• active inflammation,
• latent inflammation,
• Remission.

Inflammation in the active phase, in the absence of proper treatment or with improper therapy, is replaced by a latent state, which flows either into remission or back into the inflammatory process.

Remission is a clinical recovery when the patient does not suffer from signs of pyelonephritis, and urine tests do not show any changes.
The duration of the remission period depends on the therapy and lifestyle of the patient.

Causes

The first cause of pyelonephritis is microorganisms that enter the active stage due to improper hygiene, improper use of antibacterial agents, and changes in the pH environment.
The disease is caused by common types of bacteria:

• Proteus,
• coli,
• Staphylococci and streptococci,
• Enterococci,
• Pseudomonas aeruginosa and others.

L-types of microorganisms affect the occurrence of the disease, because they can persist in human tissues for a long time and enter the kidneys with blood.

Microbes are resistant to antibiotics, and when favorable conditions occur, they begin to actively conduct their livelihoods.

Chronic pyelonephritis may be the result of existing diseases:

• Urolithiasis disease,
• BPH,
• Cystitis,
• Diabetes,
• Gout,
• Obesity,
• Cholecystitis,
• appendicitis and others.

The onset of the disease in women is caused by pregnancy and childbirth, sexual activity.
Medical procedures - cystoscopy, catheterization, anesthesia and others - also provoke the onset of the disease.
Children suffer from this disease due to congenital pathologies - ureterocele, bladder diverticula.

Diagnosis of primary and secondary pyelonephritis

Diagnosis differs by some difficulty, the course of the disease is poorly expressed. Only a detailed questioning about the symptoms and laboratory tests help to establish the correct diagnosis.
To make a diagnosis, diagnostic methods are used:

• General analysis of urine and blood,
• bacteriological culture,
• Blood chemistry,
• Kidney biopsy.

For diagnostic purposes, pyelography, renography are performed. The patient is scheduled for catheterization to determine the amount of protein and blood enzymes that precipitate.

These methods allow you to establish the primary or secondary nature of pyelonephritis.
Primary develops in people who first complain of kidney problems.

Secondary chronic pyelonephritis is diagnosed if a person has already suffered diseases that are associated with the kidneys, or has congenital kidney pathologies.

The causes of the secondary manifestation of the disease are the same factors as in primary pyelonephritis.

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Treatment

Treatment requires a long time, the fulfillment of all the prescriptions of a specialist, adherence to proper nutrition.
The best result will complex treatment, including the elimination of the causes of the disease, and lifestyle changes.
The complex of therapeutic measures includes:

• Compliance with the regime
• Diet,
• Taking antibiotics,
• Phytotherapy,
• immunomodulatory therapy,
• Physiotherapy,
• symptomatic treatment,
• Visit to the sanatorium
• Planned treatment to avoid relapse.

The disease is bacterial, antibiotics become mandatory. The doctor prescribes antibiotics based on the tests obtained, which reveals the sensitivity of microbes to certain drugs.

Antibacterial therapy includes taking penicillins:

• amoxicillin,
• methicillin,
• oxacillin,

Depending on the sensitivity of bacteria to antibiotics, cephalosporin preparations may be prescribed:

• cefazolin,
• ceftriaxone,
• Cephalexin.

As additional antimicrobial agents prescribed sulfonamides:

• Urolesan,
• Groseptol,
• Lidaprim.

Along with antibiotics, vitamin complexes are prescribed, antiallergic drugs - diazolin, suprastin.

With an anemic form of pyelonephritis, iron intake is indicated, and the hypertensive type of the disease requires the use of antihypertensive drugs and antispasmodics.

After the main antimicrobial therapy, long-term treatment against relapses with variable use of different antibiotics is carried out.

Surgical treatment of the disease is carried out in the case of:

• Violation of the outflow of urine,
• Reflux into the ureter from the bladder,
• Presence of kidney stones
• prostate adenomas.

To speed up recovery and prevent relapses, patients are shown physiotherapy methods of treatment:

• electrophoresis,
• Galvanization,
• sodium baths.

Nutrition

Diet plays a big role in maintaining kidney function.
Medical nutrition includes compliance with the rules.