reflux nephropathy
Introduction
Introduction to reflux nephropathy Reflux nephropathy refers to vesicoureteral reflux and intrarenal reflux caused by some reason, leading to the formation of scars in the kidney, and finally can develop into end-stage renal disease and cause uremia. The disease occurs in infants and children, adults can also suffer from the disease under 50 years old, and women in adults are more likely to be pregnant, especially pregnant women. It is generally believed that the primary reflux is mostly due to the congenital defects of the ureter length, diameter, muscle tissue or innervation of the submucosal bladder. It may be very important that the submucosal ureter is too short due to ectopic ureteral orifice. When the bladder is full, the submucosal ureter may be further shortened and refluxed, which is consistent with the observation that reflux occurs only during bladder filling or during urination. The treatment includes medical treatment and surgical treatment, and the internal medicine adopts comprehensive symptomatic treatment measures to delay the arrival of uremia. In the event of uremia, blood purification should be performed and a kidney transplant can be performed. basic knowledge The proportion of illness: 0.001% Susceptible people: infants and children Mode of infection: non-infectious Complications: Hypertension Uremia
Cause
Cause of reflux nephropathy
The ureter is too short (40%):
Primary vesicoureteral reflux is the most common clinical, more common in children, is a congenital abnormality of the submucosal ureteral segment, such as congenital bladder submucosal ureter is too short, bladder deltoid muscle tissue dysplasia, etc., with the growth of children, bladder The base is well developed and most of the reflux will disappear. It is generally believed that the primary reflux is mostly due to the congenital defects of the ureter length, diameter, muscle tissue or innervation of the submucosal bladder. It may be very important that the submucosal ureter is too short due to ectopic ureteral orifice. When the bladder is full, the submucosal ureter may be further shortened and refluxed, which is consistent with the observation that reflux occurs only during bladder filling or during urination.
Urethral obstruction (40%):
Secondary vesicoureteral reflux can be secondary to bladder neck or urethral obstruction (bladder hypertension) caused by various causes, neurogenic bladder (bladder muscle weakness), bladder tuberculosis and bladder surgery (causing ureteral injury). The following are common cases of secondary disease,
(1) ureteral diverticulum: Some studies have pointed out that bladder instability and high pressure urination and ureteral congenital weakness caused by ureteral diverticulum formation plays an important role in the occurrence of VUR.
(2) Nonneurotic neurogenic bladder syndrome: This is a symptom of mental and behavioral disorders that are clinically and radiologically manifested as uncoordinated bladder sphincters, and one that is seen in children. Anatomical and neurological abnormal bladder functional obstruction. This syndrome often manifests as bedwetting, discontinuous urination, characteristic urination posture, repeated lower urinary tract infections, and morphological changes in the bladder. Urodynamic examination revealed hyperreflexia and difficulty in synoring the detrusor and sphincters. This pathological mechanism is associated with causing so-called "primary" vesicoureteral reflux and persistence. In most cases, the high activity state of the detrusor disappears after the nervous system matures.
(3) Abnormal urinary tract function: There are two types of abnormal dysfunction of urodynamics, no neurological abnormalities or abnormalities in the naked eye. The first type has reflux but the bladder has a strong urinary contraction stability. The reflux often occurs on one side, and rare reflux rheumatism or upper urinary tract abnormalities are rare. In the second type, the bladder contraction weakness and urethral closure mechanism are too strong during common urination, and reflux often occurs on both sides. Reflux nephropathy or upper urinary tract abnormalities are quite common.
Prevention
Reflux nephropathy prevention
The disease is caused by a variety of causes, prevention should start from the prevention and treatment of primary diseases, the disease that is easy to cause reflux should be carefully examined, and the diagnosis and active symptomatic treatment should be confirmed to prevent the occurrence of reflux rheumatism and progressive aggravation.
Complication
Reflux nephropathy complications Complications, hypertension, uremia
The common complication of RN in the late stage is hypertension, the incidence rate is 10.6%~38.1%; some cases can be asymptomatic for a long time, and gradually develop into the uremic stage after the late renal insufficiency.
Symptom
Reflux nephropathy symptoms common symptoms polyuria urgency urinary frequency dysuria nocturia increased proteinuria urinary tract stones
1. Urinary tract infections: Frequent urination, urgency, dysuria and fever, when severe, typical of acute pyelonephritis.
2. Hypertension: a common complication in the later stage and the most common cause of malignant hypertension in children.
3. Proteinuria: more common in male patients, although not serious, but the suggestion has developed into the renal regurgitation.
4. End-stage renal failure: reflux nephropathy is one of the main causes of end-stage renal failure in children. Pregnancy-induced hypertension can be the first symptom of reflux nephropathy. Patients with reflux nephropathy can cause rapid renal function after pregnancy. deterioration.
5. Others: such as polyuria, nocturia, enuresis, fever, abdominal pain, low back pain, urinary calculi, hematuria, etc., primary ureteral regurgitation has a familial tendency.
Examine
Reflux nephropathy
1. Urine routine: Urine routine examination reveals that in addition to a large amount of protein in the urine, the patient may have a transparent tube type or a granular tube type, and sometimes a fat tube type.
2. Selective proteinuria and urinary C3, FDP determination: type I is selective proteinuria, urine C3 and FDP values are normal, type II is non-selective proteinuria, urine C3 and FDP values often exceed normal.
3. Blood biochemical examination: In addition to the decrease of total plasma protein, white/ball can be inverted, blood cholesterol type I is increased, and type II can not be increased.
4. ESR growth rate: often 40 ~ 80mm / h, erythrocyte sedimentation rate is more parallel with edema.
5. Protein electrophoresis: 2 or can be significantly increased, and 1 and globulin are mostly lower.
6. Renal function test: Type I is normal, and type II has different degrees of abnormality.
7. Renal biopsy: can be observed by ultrastructural and immunopathological studies to provide a histomorphological basis.
Diagnosis
Diagnosis and diagnosis of reflux nephropathy
diagnosis
1. Changes in high-dose intravenous pyelography and tomography
(1) renal tubular deformation and adjacent cortical scar formation.
(2) Thinning of the renal cortex, often occurring on the unilateral or bilateral side of the renal pole, the kidney volume is reduced or morphologically disproportionate (the difference between the two kidneys is 1.5 cm).
(3) renal pelvis, renal pelvis ureteral dilatation, and no organic obstruction.
2. Different degrees of vesicoureteral reflux can be found, but about half of adult cases can have no vesicoureteral reflux.
3. Exclusion of secondary vesicoureteral reflux, at this time bladder ureteral reflux is often bilateral.
Differential diagnosis
1. Allergic purpura nephritis: occurs in adolescents, with typical skin purpura, may be associated with joint pain, abdominal pain and melena, more than 1 to 4 weeks after the appearance of rash, hematuria and / or proteinuria, typical rash Helps identify.
2. Systemic lupus erythematosus: occurs in adolescents and middle-aged women. Multiple clinical antibodies and immunological examinations show multiple antibodies, which are generally not difficult to identify.
3. Hepatitis B virus-associated nephritis: occurs in children and adolescents, with proteinuria or NS as the main clinical manifestations. The diagnosis is based on the following three points: 1 serum HBV antigen is positive. 2 suffering from glomerulonephritis, and can exclude secondary glomerulonephritis such as lupus erythematosus. 3 HBV antigen was found in the kidney biopsy section.
4. Diabetic nephropathy: It occurs in middle-aged and elderly people. It is common in diabetic patients with a disease duration of more than 5 years. In the early stage, it can be found that the increase of urinary microalbumin is increased, and then it gradually develops into a large amount of proteinuria and nephrotic syndrome. A history of diabetes and characteristic fundus changes contribute to a differential diagnosis.
5. Renal amyloidosis: occurs in middle-aged and elderly, and renal amyloidosis is part of multiple organ involvement in the body. Primary amyloidosis primarily affects the heart, kidneys, digestive tract (including the tongue), skin, and nerves. Secondary amyloidosis is often secondary to chronic suppurative infections, tuberculosis, malignant tumors and other diseases, mainly involving the kidney, liver and spleen. When the kidney is involved, the volume increases, often showing NS. Renal amyloidosis often requires a kidney biopsy to confirm the diagnosis.
6. Myeloma nephropathy: occurs in middle-aged and elderly people, more common in men, patients may have characteristic clinical manifestations of multiple myeloma, such as bone pain, serum immunoglobulin increased, protein electrophoresis with M protein and urine The weekly protein is positive, and the bone marrow image shows abnormal proliferation of plasma cells. NS can occur when glomeruli are involved.
