1. Pyelonephritis in children. Etiology, Pathogenesis, Clinics, Diagnostics, Treatment and Prophylactic Lecturer: Nykytyuk S.O.

7. Plan of the lecture Definition of pyelonephritis Definition of pyelonephritis Pyelonephritis classification Pyelonephritis classification Clinical manifestation Clinical manifestation Methods of examinations Methods of examinations Treatment of the different kinds of pyelonephritis Treatment of the different kinds of pyelonephritis

8. Pyelonephritis Is an infectious inflammatory disease of tubulointerstitial renal tissue Is an infectious inflammatory disease of tubulointerstitial renal tissue

9. E coli is the most common by far, causing 75-90% of UTIs. E coli is the most common by far, causing 75-90% of UTIs. Klebsiella species Klebsiella species Proteus species Proteus species Enterococcus species Enterococcus species Staphylococcus saprophyticus Staphylococcus saprophyticus

10. Etiology Hospital patients: Hospital patients: –Escherichia coli: 40% –Coagulase-negative staphylococci: 3% –'Other' Gram-negative bacteria: 25% –'Other' Gram-positive bacteria: 16% –Candida albicans: 5% –Proteus mirabilis: 11% Community-acquired Urinary Tract Infections: Community-acquired Urinary Tract Infections: –Escherichia coli: 80% –Coagulase-negative staphylococci: 7% –'Other' Gram-negative bacteria: 4% –'Other' Gram-positive bacteria: 3% –Proteus mirabilis: 6%

11. Classification of pyelonephritis Form Form –Primary –Secondary Obstructive Obstructive Dysembriogenetic Dysembriogenetic dysmetabolic dysmetabolic Course Course –Acute –Chronic Manifest recurrent form Manifest recurrent form Latent form Latent form

12. Classification of pyelonephritis Period Period –Active –Period of partial remission –Period of full clinical and laboratory remission Renal function Renal function –Without disorders of renal function –With disorders of renal function –Chronic renal insufficiency

13. Clinical Manifestation Extrarenal Extrarenal –Syndrome of intoxication –Pain syndrome –Disuria Renal Renal –Leukocyturia –Bacteriuria (colony count over 100 000/ml) –Mild proteinuria –Slight hematuria –TLC and ESR are high –Decreasing of total diuresis –Decreasing of specific gravity

14. Clinical Manifestation Preschoolers and schoolchildren Vomiting, diarrhea, abdominal pain Vomiting, diarrhea, abdominal pain Fever Fever Strong-smelling urine, enuresis, dysuria, urgency, frequency, flank pain or new enuresis Strong-smelling urine, enuresis, dysuria, urgency, frequency, flank pain or new enuresis

15. Clinical Manifestation Neonates Jaundice Jaundice Hypothermia or fever Hypothermia or fever Failure to thrive Failure to thrive Poor feeding Poor feeding Vomiting VomitingInfants Poor feeding Poor feeding Fever Fever Vomiting, diarrhea Vomiting, diarrhea Strong-smelling urine Strong-smelling urine

16. Physical: Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease. Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease. Costovertebral angle (CVA) tenderness Costovertebral angle (CVA) tenderness Abdominal tenderness or mass Abdominal tenderness or mass Palpable bladder Palpable bladder Dribbling, poor stream, or straining to void Dribbling, poor stream, or straining to void Examine external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse. Examine external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse.

17. Plan of examination Fool blood count Fool blood count urinanalysis urinanalysis Nechepurenko’s test Nechepurenko’s test Kakovsky-Addis test Kakovsky-Addis test Ambyrze’s test Ambyrze’s test urine culture (more than 10,000 CFU from bladder) urine culture (more than 10,000 CFU from bladder) Zimnitskiy’s test Zimnitskiy’s test Biochemical test of blood Biochemical test of blood –Serum level of electrolytes –total protein, albumin and globulin level –residual nitrogen, blood urea, creatinine Creatinine clearance Creatinine clearance Ultrasonography of kidneys and urinary bladder. Ultrasonography of kidneys and urinary bladder. Excretory urography Excretory urography Nuclear cystography Nuclear cystography

18. Data of excreatory urography Acute pyelonephritis Acute pyelonephritis –Kidney is enlarged –Hypotonia of the ureters Chronic pyelonephritis Chronic pyelonephritis –Asymmetry of the kidneys –Deformation of calyco-pelvic system –Irregular excretion of contrast substance up to adynamia of calico-pelvic system chronic secondary pyelonephritis chronic secondary pyelonephritis –Obstruction of the urinary tract –Congenital malformations –Refluxes –Renal dysplasia

19. double kidney

20. dystopia

21. dystopia and nephroptosis

22. L- and S-like kidneys

23. Renal multicystosis polycystic kidney

30. Ultrasound examination of an 18-mo-old boy with autosomal dominant polycystic kidney disease

34. Treatment of pyelonephritis Complete bed rest for 3-4 days. Complete bed rest for 3-4 days. Diet N 5a (quantity of liquid is 1.5 times more than age necessities. Fresh fruits and vegetables with diuretic properties are desirable, especially melons) Diet N 5a (quantity of liquid is 1.5 times more than age necessities. Fresh fruits and vegetables with diuretic properties are desirable, especially melons) At exacerbation period it is necessary to give milk-vegetable food with limitation of protein (1.5-2 g/kg) and salt (2-3 g) than diet 5 a

35. Antibacterial treatment (for 8-10 days, two cycles) Antibacterial treatment (for 8-10 days, two cycles) - BENZYLPENICILLIN Na - 20.000-50.000 U/kg – 7-10 days –amoxiclav 25-50 mg/kg, –or cefotaxim 100-150 mg/kg, –or ceftriaxon 100 mg/kg, –or ciprophloxacin 10-20 mg/kg per day in 2 equal doses. –or macropen 30-50 mg/kg –Gentamicyn 4-7 mg/kg

36. Uroseptics Furadonin, furagin 5-8 mg/kg 4 times per day Furadonin, furagin 5-8 mg/kg 4 times per day Nalidixic acid (negram, nevigramon) 50-60 mg/kg 4 times per day Nalidixic acid (negram, nevigramon) 50-60 mg/kg 4 times per day 5-NOK, nitroxolin 8-10 mg/kg 4 times per day 5-NOK, nitroxolin 8-10 mg/kg 4 times per day Biseptol (sulfamethoxazole, trimetoprim 2 mg/kg) twice a day Biseptol (sulfamethoxazole, trimetoprim 2 mg/kg) twice a day

37. Phytotherapy Canefron 10-40 dr. or dragee 3 times/day Canefron 10-40 dr. or dragee 3 times/day Urolesan 10-40 dr. 3 times/day Urolesan 10-40 dr. 3 times/day

38. Plan of the lecture Definition of glomerulonephritis Definition of glomerulonephritis Glomerulonephritis classification Glomerulonephritis classification Clinical manifestation Clinical manifestation Methods of examinations Methods of examinations Treatment of the different kinds of glomerulonephritis Treatment of the different kinds of glomerulonephritis

39. Definition of the glomerulonephritis Is an infectious allergic renal disease with primary lesions of glomeruli. Is an infectious allergic renal disease with primary lesions of glomeruli. immunologically mediated inflammation of renal glomerules accompanied by hematuria, proteinuria and azotemia immunologically mediated inflammation of renal glomerules accompanied by hematuria, proteinuria and azotemia

40. Etiology: a) bacterial ( staphylococcal) infection; b) Viral ( hepatitis B, mononucleosis); c) Fungal ( histoplasmosis ); d) Parasitic (toxoplasmosis) a) bacterial ( staphylococcal) infection; b) Viral ( hepatitis B, mononucleosis); c) Fungal ( histoplasmosis ); d) Parasitic (toxoplasmosis)

41. Classification of glomerulonephritis acute acute chronic chronic subacute (malignant) glomerulonephritis subacute (malignant) glomerulonephritis

42. Classification of acute glomerulonephritis FORM FORM –With nephritic syndrome –With nephrotic syndrome –With isolated urinary syndrome –With nephrotic syndrome, hematuria and hypertension Activity of renal process Activity of renal process –Period of initial manifestations –Period of comprehensive manifestations –Period of reverse development –Transition to chronic glomerulonephritis

43. Classification of acute glomerulonephritis Without disorders of renal function Without disorders of renal function With disorders of renal function With disorders of renal function Acute renal insurfficiency Acute renal insurfficiency

44. nephritic syndrome edema, edema, arterial hypertension, arterial hypertension, urinary syndrome (proteinuria, hematuria, casturia) urinary syndrome (proteinuria, hematuria, casturia)

45. nephrotic syndrome massive edema massive edema significant proteinuria (more than 3 g/l) significant proteinuria (more than 3 g/l) hypoproteinemia hypoproteinemia hypercholesterolemia hypercholesterolemia

46. Classification of chronic glomerulonephritis FORM FORM –Nephrotic form –Hematuric form – Mixed form Activity of renal process Activity of renal process –Period of exacerbation –Period of partial remission –Period of full clinical and laboratory remission Renal function Renal function –Without disorders of renal function –With disorders of renal function –Chronic renal insurfficiency

47. Subacute (malignant) glomerulonephritis –Without disorders of renal function –With disorders of renal function –Chronic renal insurfficiency

48. Clinical manifestation Extrarenal symptoms Extrarenal symptoms –edema –arterial hypertension renal symptomes renal symptomes –oliguria and anuria –hematuria –proteinuria (mild, moderate, significant) –leucocyturia (rare) –casts (cylinders): hyaline, epithelial, granular, waxy metabolic syndrome metabolic syndrome –disorder of water-electrolyte metabolism –disorder of protein metabolism –disorder of lipid metabolism

49. Clinical manifestation of acute glomerulonephritis Diagnosis can generally be established on the basis of the following clinical and laboratory criteria: Diagnosis can generally be established on the basis of the following clinical and laboratory criteria: Acute onset; Acute onset; Edema; Edema; Hematuria with red blood cell casts in the sediment; Hematuria with red blood cell casts in the sediment; Hypertension; Hypertension; Evidence of antecedent streptococcal infection; Evidence of antecedent streptococcal infection; Lowered serum betaC globulin concentration; Lowered serum betaC globulin concentration; Spontaneous improvement in a few days or weeks. Spontaneous improvement in a few days or weeks.

50. Plan of examination Fool blood count Fool blood count urinanalysis urinanalysis Nechepurenko’s test Nechepurenko’s test Kakovsky-Addis test Kakovsky-Addis test Ambyrze’s test Ambyrze’s test urine culture urine culture Zimnitskiy’s test Zimnitskiy’s test Biochemical test of blood Biochemical test of blood –Serum level of electrolytes –total protein, albumin and globulin level –cholesterole –residual nitrogen, blood urea, creatinine Creatinine clearance Creatinine clearance Ultrasonography of kidneys and urinary bladder. Ultrasonography of kidneys and urinary bladder. Excretory urography Excretory urography

51. Creatinine clearance newborn 40-65 ml/min/1.73 m2 newborn 40-65 ml/min/1.73 m2 1 yr and older 60-120 ml/min/1.73 m2 1 yr and older 60-120 ml/min/1.73 m2

52. cholesterole – 3.6-6.2 mmol/l residual nitrogen – 14.3-28.6 mmol/l blood urea – 2.5-8.3 mmol/l creatinine – 0.035-0.1 mmol/l

53. Renal functional tests azotemia azotemia elevation of serum creatinine, serum inorganic phosphate elevation of serum creatinine, serum inorganic phosphate hyperkalemia hyperkalemia metabolic acidosis metabolic acidosis The total serum protein concentration is slightly decreased The total serum protein concentration is slightly decreased 40% of children has elevated serum lipids 40% of children has elevated serum lipids the levels of serum IgG and IgM and C1 is also increased the levels of serum IgG and IgM and C1 is also increased Anemia is common in the early phase of AGN. Anemia is common in the early phase of AGN.

54. Treatment of acute glomerulonephritis Complete bed rest until the symptoms subside. Complete bed rest until the symptoms subside. Diet N 7a (Restriction of proteins, low quantity of fats & carbohydrates, water, salt, allergenic foods) Diet N 7a (Restriction of proteins, low quantity of fats & carbohydrates, water, salt, allergenic foods) salt salt –at the 4-5 week 0.5 g/day –at the 8 week 1.5 g/day –for nest 2 yrs 50 mg/kg proteins (in case renal failure) proteins (in case renal failure) –at the first 1-4 days - 0.5-1g/kg –5-7 days – 1-1.5 g/kg –7-10 days – 2.5 g/kg liquid 15 ml/kg (400 ml/m2)

55. Treatment of acute glomerulonephritis Antibacterial treatment (for 8-10 days, two cycles) Antibacterial treatment (for 8-10 days, two cycles) - BENZYLPENICILLIN Na - 20.000-50.000 U/kg – 7-10 days –amoxiclav 25-50 mg/kg, –or cefotaxim 100-150 mg/kg, –or ceftriaxon 100 mg/kg, –or ciprophloxacin 10-20 mg/kg per day in 2 equal doses. –or macropen 30-50 mg/kg treatment of chronic locus of infection treatment of chronic locus of infection

56. Treatment of acute glomerulonephritis membranostabilizers membranostabilizers –tocoferol acetatis Improvement of renal flow Improvement of renal flow –electrophoresis with nicotinic acid or heparin – i/v injections of euphyllin 2 mg/kg 3 times per day euphyllin 2 mg/kg 3 times per day trental 5 mg/kg 3 times per day (amp. 5 ml 2 % sol., dragee 100mg) or dipiridamol 5 mg/kg 3 times per day per os trental 5 mg/kg 3 times per day (amp. 5 ml 2 % sol., dragee 100mg) or dipiridamol 5 mg/kg 3 times per day per os Vitamin therapy Vitamin therapy

57. Treatment of acute glomerulonephritis Management of edema Management of edema –lasix 1-2 mg/kg i/m –hypothiazid 0.5-1 mg/kg per os Management of hypertension and eclampsia Management of hypertension and eclampsia –renin-angiotensin-aldosteron system antagonists captopril, cozaar, analapril 0.25-0.5 mg/kg captopril, cozaar, analapril 0.25-0.5 mg/kg in crisis: 0.1 ml/kg of 1% papaverini + 0.1 ml/kg of 0.5 % dibazoli in crisis: 0.1 ml/kg of 1% papaverini + 0.1 ml/kg of 0.5 % dibazoli

58. Treatment of subacute glomerulonephritis 1. Corticosteroids 2-3 mg/kg/day + cyclophosphamide 4-5 mg/kg/day or cyclosporin A 5-10 mg/kg/day 2. trental 5 mg/kg 3 times per day or dipiridamol 5 mg/kg 3 times per day per os 3. heparin (fraxiparin) 500 IU/kg/day 4. Plasmapheresis pulse-therapy pulse-therapy Corticosteroids 20-25 mg/kg/day i/v for 3-6 times

59. Treatment of chronic glomerulonephritis 1. dipiridamol 10 mg/kg 3 times per day per os + Indometacin 1-3 mg/kg in case of renal failure in case of renal failure Corticosteroids 2-3 mg/kg/day + cyclosporin A 5-10 mg/kg/day +dipiridamol 5 mg/kg 3 times per day per os