pyelonephritis
Introduction
Introduction to pyelonephritis Pyelonephritis (pyelonephritis) refers to inflammation of the kidney sputum, mostly caused by bacterial infection, usually associated with urinary tract inflammation, clinically difficult to distinguish strictly, according to clinical course and disease, pyelonephritis can be divided into acute and chronic two stages, chronic pyelonephritis Nephritis is an important cause of chronic renal insufficiency. Pyelonephritis is a renal pelvis, renal tubules, renal tubules, and renal interstitial infectious inflammation caused by direct invasion of various pathogenic microorganisms. basic knowledge The proportion of illness: 0.07% Susceptible people: no specific population Mode of infection: non-infectious Complications: urinary tract obstruction, acute renal failure, shock
Cause
Causes of pyelonephritis
Pyelonephritis is a renal pelvis and renal tubule, renal interstitial infectious inflammation caused by direct invasion of various pathogenic microorganisms. In recent years, it has been found that there are pathogenic antigens in renal scar tissue of some patients with pyelonephritis, indicating that it is in the renal pelvis. In the pathogenesis of nephritis, immune kidney tissue damage can also be one of the causes of inflammation.
Systemic factors (10%):
Such as diabetes, high blood pressure, long-term hypokalemia, heart failure and many chronic wasting diseases are easy to be complicated by kidney and nephritis. Some scholars believe that in addition to the ascending infection, kidney and nephritis can also be directly infected by blood and lymphatic vessels and nearby organs, and has a certain relationship with immunity.
Estrogen secretion (20%):
Pregnancy women have increased estrogen secretion, decreased ureteral tension, weakened peristalsis, resulting in poor urinary tract and high incidence of urinary reflux. Therefore, most urinary tract infections during pregnancy are kidney and nephritis. Renal nephritis is caused by ascending infection of cystitis, especially bladder-ureteral reflux, which is an important cause of ascending infection.
Cystitis (20%):
If not treated promptly or adequately, about 30 to 50% can cause pyelonephritis.
Urinary tract obstruction (15%):
Such as urinary calculi, tumors, stenosis, prostatic hypertrophy and neurogenic bladder, etc., resulting in poor urine flow, reduced local antibacterial ability, is conducive to infection and increased pressure, is an important cause of kidney and kidney nephritis. About 60% of patients with urinary tract obstruction have renal nephritis.
Renal parenchymal lesions (15%):
Such as glomerulonephritis, renal cysts, kidney tumors and chronic tubulointerstitial diseases. Can reduce the local antibacterial ability of the kidney, and easily complicated with kidney and nephritis.
Because women have short urethra, bacteria are easy to invade, and there are many opportunities for infection, so the incidence of women is 8 to 10 times higher than that of men. E. coli exists in the female urethra, and sexual intercourse is often an important cause of infection.
Prevention
Pyelonephritis prevention
For patients with chronic pyelonephritis, it is necessary to strengthen the system, improve the body's defense ability, eliminate various predisposing factors such as diabetes, kidney stones and urinary tract obstruction, etc., actively seek and remove inflammatory lesions, such as male prostatitis, female paraurethral glands Inflammation, vaginitis and cervicitis, reduce unnecessary catheterization and urinary tract equipment operation, such as the need to retain catheterization should be preventive application of antibacterial drugs, women who are devastating sexual life, should urinate after sex, and Oral administration of a dose of SMZ-TMP, attention should be paid to the cleansing of the vulva during pregnancy and menstruation. Menopause takes 1 to 2 mg of nylestriol once or twice a month to enhance local low resistance.
Complication
Pyelonephritis complications Complications, urinary tract obstruction, acute renal failure, shock
Patients with pyelonephritis, after effective antibiotic treatment, the symptoms will be significantly improved within 2 to 3 days. If there is no improvement, the symptoms will worsen, there will be persistent high fever, and the white blood cells will increase significantly. The complications should be considered, and the common complications of pyelonephritis should be considered. Have:
1, renal papillary necrosis: is one of the serious complications, often occur in patients with pyelonephritis of diabetes or urinary tract obstruction, can be complicated by sepsis or lead to acute renal failure.
2, peri-renal abscess: from the direct expansion of severe pyelonephritis, accounting for 90%, pathogenic bacteria are mostly Gram-negative bacilli, common in E. coli, more common in diabetes, urinary tract stones and other unfavorable factors, patients often appear obvious Unilateral low back pain and tenderness, when the waist bends to the healthy side, the pain is intensified, and the treatment should use strong antibiotics, strengthen supportive treatment, or cut drainage.
3, concurrent with infectious stones: the composition of the stone is mainly ammonium magnesium phosphate, which is due to urease contained in Proteus, etc., can decompose urea in the urine, make urea alkaline, and phosphate in alkaline urine The solubility is significantly reduced, and precipitation is easily formed to form magnesium ammonium phosphate and apatite stones.
4, Gram-negative bacilli sepsis: more often in acute, severe pyelonephritis, performance is dangerous, sudden chills, high fever, often caused by shock, mortality rate of 50%, should actively give strong antibiotics, strengthen supportive treatment.
Symptom
Symptoms of pyelonephritis common symptoms azotemia hypokalemia protein renal abscess polyuria urinary erectile urinary protein fatigue low fever kidney nipple and renal pelvis bleeding
1. History: The history of acute pyelonephritis can be used as a reference for diagnosis, but it cannot be used as a basis. Because most patients with non-obstructive chronic pyelonephritis have no history of urinary tract infection or other history of kidney disease, they often fall into the onset of disease. The symptoms of hemorrhagic disease can be the first symptom of the patient and should be noted at the time of diagnosis.
2, clinical manifestations: intermittent reaction urinary tract irritation symptoms, generally lighter, not as acute pyelonephritis, often accompanied by fatigue, loss of appetite, back pain, may have low fever or no fever, advanced can occur due to renal damage Dizziness, headache, nausea, vomiting and other uremia symptoms, can also appear polyuria, nocturia, hypokalemia, hyponatremia or chronic renal tubular acidosis, some patients insidious or atypical, should pay attention.
Examine
Examination of pyelonephritis
1, urine routine: urine protein is generally a small amount or a small amount, if the urine protein > 3.0 / 24 hours, it suggests the possibility of non-the disease, urine sediment can have a small amount of red blood cells and white blood cells, if found white blood cell cast is helpful for diagnosis, but Not unique to this disease.
2, urine culture: the same as acute pyelonephritis, but the positive rate is low, sometimes need to be repeatedly checked to obtain a positive result, about 20% of patients with negative urine bacterial culture can find the original pulp type strain, the pathogenic bacteria in the antibacterial Under the action of drugs, antibodies, etc., in order to adapt to a poor environment, a mutant ability to survive, although the membrane is broken, but the original pulp is still, once the environment is favorable, it can reproduce, urine culture and urine after bladder sterilization When the liquid antibody-encapsulated bacteria is positive, it can help diagnose the disease, and it can be differentiated from cystitis.
3, renal function test: usually have renal tubular dysfunction (urinary concentrating function decreased, phenol red excretion rate decreased, etc., may have urinary sodium, increased urinary potassium excretion, metabolic acidosis; blood potassium can be increased when urine is low, late appearance Glomerular dysfunction, increased blood urea nitrogen and creatinine, and causes uremia.
4, X-ray angiography: visible renal pelvis and renal pelvis deformation, the shadow is irregular or even reduced.
Diagnosis
Diagnosis and diagnosis of pyelonephritis
diagnosis
Acute pyelonephritis usually has typical symptoms and abnormal urine findings, and diagnosis is not difficult.
Differential diagnosis
If there is only high fever and the urinary tract symptoms are not obvious, it should be differentiated from various fever diseases. Abdominal pain and low back pain should be differentiated from cholecystitis, appendicitis, pelvic inflammatory disease, perirenal abscess, etc. Can clearly diagnose, chronic pyelonephritis urinary tract symptoms are not obvious, no significant changes in urine routine or intermittent urine abnormalities, easy to be misdiagnosed, in women, who have unknown heat, backache, fatigue, mild urinary tract symptoms should not be Considering the possibility of this disease, it is necessary to repeatedly check the urine routine and culture and find evidence. Chronic pyelonephritis with hypertension needs to be differentiated from hypertension. In addition, it is necessary to identify the following diseases.
1, kidney tuberculosis: the genital tract tuberculosis is often accompanied by, it is the most common extrapulmonary tuberculosis, multiple bloodline infections, acute fever (low fever), night sweats, low back pain, frequent urination, urgency, dysuria , hematuria and other symptoms, about 20% of cases can be no clinical manifestations, also known as silent urinary sensation, renal parenchymal destruction after a few years, tuberculous granuloma, cheese-like changes involving the medulla, nipple area, followed by nipple necrosis, renal pelvis deformation, cortical thinning, even involving the surrounding tissues of the kidney, late renal function damage, bladder contracture, lung X-ray examination, prostate, epididymis, pelvic tuberculosis detection helps the diagnosis of the disease, urine examination There are hematuria (microscopic hematuria or gross hematuria), pyuria, positive skin test (PPD), urinary tuberculosis culture, the detection rate is as high as 90% or more, and intravenous pyelography can only find more advanced cases, in recent years, poly-enzyme reaction ( PCR detection of urinary tuberculosis DNA has been widely used in the diagnosis, its specificity, the positive rate is as high as 95%.
2, chronic glomerulonephritis: If there is edema, a large number of proteinuria is not difficult to identify, the urinary protein content of pyelonephritis is generally below 1 ~ 2g / d, if more than 3g are mostly glomerular lesions, but the disease and Occult nephritis is difficult to identify, the latter has more red blood cells in the urine routine, and pyelonephritis is mainly white blood cells. In addition, urine culture, long-term observation of patients with low fever, frequent urination and other symptoms can also help identify, late nephritis secondary Urinary tract infection, identification is difficult, at this time can be detailed medical history, combined with clinical characteristics to analyze.
3, prostatitis: men over the age of 50 due to prostate hyperplasia, hypertrophy, placement of catheters, cystoscopy, etc. are easy to get this disease, acute prostatitis in addition to chills and fever, the total number of white blood cells increased, lumbosacral and will Pussy pain, resulting in restlessness, frequent urination, dysuria, urine examination, pus cells, and easy to be confused with acute cystitis, chronic prostatitis, except for abnormal urine test, clinical symptoms are not obvious, prostatic fluid examination obtained by prostate massage, white blood cells The number > 10 / HP, B-pre-existing gland helps differential diagnosis.
