Congenital diseases of the kidneys and other organs of the urinary system in children

Acute renal failure

This is a nonspecific syndrome that occurs with acute loss of homeostatic functions of the kidneys. Symptoms are pronounced and appear suddenly. The volume of urine excreted stops or sharply decreases. Toxic substances are not removed from the child’s body; intoxication occurs with metabolic products. Within a few days, symptoms resembling poisoning appear - the child becomes lethargic, feels sick or vomits. Source: O.I. Andriyanova, F.K. Manerov, Yu.A. Churlyaev, I.G. Khamin Causes and treatment of acute renal failure in children // General resuscitation, 2007, III, 4, pp. 70-75

Why does the disease occur and how does it progress in children of different ages?

On the first day, the newborn may not urinate; a sign of pathology is the absence of urine on the third day. Features of the physiological structure of the kidneys in the neonatal period do not allow us to determine the disease in infants in the first two days. Source: Iseki K., Ikemiya Y, Iseki C., Takishita S. Proteinuria and the risk of developing end-stage renal disease // Kidney Int. 2003; 63:1468-1473

During the newborn period, problems may arise for the following reasons:

• low birth weight;
• developmental anomalies, heart defects;
• congenital vascular diseases of the renal arteries;
• absence of kidneys;
• urinary tract disorder;
• blood infection;
• dehydration due to intrauterine infection;
• birth trauma with blood loss;
• acute lack of oxygen during labor;
• blockage of the renal vein.

In children from 1 month to 3 years, problems arise against the background of acute intestinal pathologies, kidney infections, hemolysis, and metabolic disorders.

The causes of acute renal failure in children 3-14 years old are: severe injuries, drug poisoning, infectious diseases, the presence of stones or tumors that block the bile ducts.

Stages of development and symptoms

• Preanuric – urinary function worsens. Weakness, pallor, lethargy, lethargy appear, swelling is visible (nephrotic syndrome), diarrhea, shortness of breath, and rapid heartbeat are observed.
• Anuric – lasts 10-14 days, toxins and metabolic products are not removed from the body, salts and water are retained. The acid-base balance is disturbed, and acute intoxication with metabolic products develops. There is severe thirst, an unpleasant taste in the mouth, and loss of appetite. Muscle tone decreases, peeling of the skin is visible.
• Polyuric – sharply increases urine output. The child is in serious condition, there is drowsiness, swelling, headache, nausea. Dystrophy of the heart muscle develops. An urgent kidney transplant is required.
• Restorative - blood vessels return to function, urine volume and capillary permeability are normalized.

How is diagnosis carried out?

The main symptom of acute renal failure in children, by which pathology can be suspected, is a sharp reduction in urine volume. To confirm the diagnosis, urine and blood tests are necessary.

In acute renal failure the following is observed:

• decreased specific gravity of urine;
• increase in urea, creatinine;
• increased levels of sodium salts.

Additionally, ultrasound of the kidneys, cystoscopy, and radiography are performed.

Pyelonephritis in children: classification, course, diagnosis and treatment

Pyelonephritis is a nonspecific infectious and inflammatory disease of the kidneys with predominant damage to the pyelocaliceal system (PSS), tubules and interstitium. According to the World Health Organization (WHO) classification, pyelonephritis belongs to the group of tubulointerstitial nephritis and is actually tubulointerstitial nephritis of infectious origin [1, 2, 6].

Today, the question of the primary and secondary nature of pyelonephritis, especially chronic, as well as the role of urinary tract obstruction in the development of its various variants remains relevant [3, 7]. These signs form the basis for the classification of pyelonephritis.

There is no generally accepted classification of pyelonephritis today. The most frequently used classification is proposed by M. Ya. Studenikin and co-authors in 1980 (Table 1), which determines the form (primary, secondary), nature of the course (acute, chronic), disease activity and kidney function. V. G. Maydannik and co-authors (2002) also suggested indicating the stage of the pyelonephritic process (infiltrative, sclerotic) and the degree of disease activity [2, 3, 6, 7, 9].

Primary is called pyelonephritis, in which the examination fails to identify any factors that contribute to the fixation of microorganisms in the kidney tissue, that is, when a microbial inflammatory process develops in an initially healthy organ. Secondary pyelonephritis is caused by specific factors.

In turn, secondary pyelonephritis is divided into obstructive and non-obstructive. Secondary obstructive develops against the background of organic (congenital, hereditary and acquired) or functional disorders of urodynamics; secondary non-obstructive - against the background of dysmetabolic disorders (secondary dysmetabolic pyelonephritis), hemodynamic disorders, immunodeficiency states, endocrine disorders, etc. [2, 3, 6].

The concept of primary or secondary disease undergoes significant changes over time. Clinical and experimental data convincingly indicate that without a preliminary disturbance of urodynamics, the pyelonephritic process practically does not develop. Obstruction of the urinary tract implies not only the presence of a mechanical obstruction to the flow of urine, but also functional disturbances of activity, such as hyper- or hypokinesia, dystonia. From this point of view, primary pyelonephritis no longer implies any absence of disturbance in the passage of urine, since dynamic changes in urination are not excluded [1, 2, 6].

Primary pyelonephritis is quite rare - no more than 10% of all cases, and its share in the structure of the disease decreases as methods for examining the patient improve.

It is also very conditional to classify secondary dismetabolic pyelonephritis as a non-obstructive group, since with this option, obstruction of the renal tubules and collecting ducts by salt crystals is always observed [2, 6].

Acute and chronic pyelonephritis are distinguished depending on the duration of the pathological process and the characteristics of clinical manifestations.

Acute or cyclic course of pyelonephritis is characterized by the transition of the active stage of the disease (fever, leukocyturia, bacteriuria) into a period of reverse development of symptoms with the development of complete clinical and laboratory remission with a duration of the inflammatory process in the kidneys of less than 6 months. The chronic course of pyelonephritis is characterized by the persistence of symptoms of the disease for more than 6 months from its onset or the presence of at least two relapses during this period and, as a rule, is observed with secondary pyelonephritis. According to the nature of the course, latent or recurrent chronic pyelonephritis is distinguished. The recurrent course is characterized by periods of exacerbation, occurring with the clinical picture of acute pyelonephritis (urinary and pain syndromes, symptoms of general intoxication), and remissions. The latent course of the chronic form is characterized only by urinary syndrome of varying severity [2, 3, 7].

As the experience accumulated in the Nephrology Department of the Russian Children's Clinical Hospital shows, chronic pyelonephritis is always secondary and develops most often as an obstructive-dysmetabolic type against the background of dismetabolic nephropathy, neurogenic bladder dysfunction, obstructive uropathy, etc. Among 128 patients with chronic pyelonephritis that we observed during 2004 g., in 60 (46.9%) the disease developed against the background of dysmetabolic nephropathy, in 40 (31.2%) - against the background of neurogenic bladder dysfunction, in 28 (21.9%) - against the background of obstructive uropathies (vesi- ureteral reflux, hydronephrosis, hypoplasia and aplasia of the kidney, horseshoe kidney, lumbar dystopia of the kidney, etc.).

Depending on the severity of the signs of the disease, one can distinguish the active stage of chronic pyelonephritis, partial clinical and laboratory remission and complete clinical and laboratory remission.

The activity of chronic pyelonephritis is determined by a combination of clinical symptoms and changes in urine and blood tests.

Clinical symptoms include:

• fever, chills;
• pain syndrome;
• dysuric phenomena (when combined with cystitis).

Urinalysis indicators are as follows:

• bacteriuria >100,000 microbial bodies in 1 ml;
• leukocyturia > 4000 in urine analysis according to Nechiporenko.

Blood test indicators:

• leukocytosis with rod-nuclear shift;
• anemia;
• increased erythrocyte sedimentation rate (ESR).

Partial clinical and laboratory remission is characterized by the absence of clinical manifestations with persistent urinary syndrome. At the stage of complete clinical and laboratory remission, neither clinical nor laboratory signs of the disease are detected.

With exacerbation of recurrent pyelonephritis, an acute clinical form is observed, although general clinical symptoms are usually less pronounced. During periods of remission, the disease often does not manifest itself at all or only urinary syndrome occurs.

Often, in the chronic form, children experience infectious asthenia: irritability, fatigue, poor performance at school, etc.

Leukocyturia in pyelonephritis is neutrophilic in nature (more than 50% neutrophils). Proteinuria, if present, is insignificant, less than 1 g/l, and correlates with the severity of leukocyturia. Often, children with pyelonephritis have erythrocyturia, usually single unchanged red blood cells.

In the chronic dismetabolic variant, crystalluria is detected in a general urine analysis; in a biochemical urine analysis, increased levels of oxalates, phosphates, urates, cystine, etc.; in a urine analysis for the anti-crystal-forming ability of urine, a decrease in the ability to dissolve the corresponding salts, positive tests for calcification and the presence of peroxides.

Diagnosis of chronic pyelonephritis is based on the protracted course of the disease (more than 6 months), repeated exacerbations, identification of signs of damage to the tubulointerstitium and CLS due to bacterial infection [1, 2, 6, 8].

In any course of the disease, the patient must undergo a full range of studies aimed at establishing the activity of the microbial inflammatory process, the functional state of the kidneys, the presence of signs of obstruction and metabolic disorders, and the state of the renal parenchyma [1, 2, 6]. We offer the following set of studies for chronic pyelonephritis, which allows us to obtain answers to the questions posed.

1. Research to identify the activity of the microbial inflammatory process.

Mandatory laboratory tests:

• Clinical blood test.
• Biochemical blood test (total protein, protein fractions, urea, fibrinogen, C-reactive protein (CRP)).
• General urine analysis.
• Quantitative urine tests (according to Nechiporenko, Amburge, Addis-Kakovsky).
• Morphology of urine sediment.
• Urine culture for flora with quantitative assessment of the degree of bacteriuria.
• Urine antibioticogram.
• Biochemical examination of urine (daily excretion of protein, oxalates, urates, cystine, calcium salts, indicators of membrane instability - peroxides, lipids, anti-crystal-forming ability of urine).

Additional laboratory tests:

• Urine examination for chlamydia, mycoplasma, ureaplasma (polymerase chain reaction, cultural, cytological, serological methods), fungi, viruses, mycobacterium tuberculosis (urine culture, express diagnostics).
• Study of immunological status (secretory immunoglobulin A (sIgA), state of phagocytosis).

2. Studies to assess the functional state of the kidneys and tubular apparatus.

Mandatory laboratory tests:

• Level of creatinine, urea in the blood.
• Zimnitsky's test.
• Clearance of endogenous creatinine.
• Study of pH, titratable acidity, ammonia excretion.
• Diuresis control.
• Rhythm and volume of spontaneous urination.

Additional laboratory tests:

• Urinary excretion of β2-microglobulin (mg).
• Urine osmolarity.
• Urine enzymes.
• Ammonium chloride test.
• Zimnitsky test with dry food.

3. Instrumental research.

Required:

• Blood pressure measurement.
• Ultrasound examination (ultrasound) of the urinary system.
• X-ray contrast studies (void cystography, excretory urography).
• Functional methods for studying the bladder (uroflowmetry, cystometry, profilometry).

Additional:

• Doppler ultrasound of renal blood flow.
• Excretory urography with furosemide test.
• Cystourethroscopy.
• Radionuclide studies (scintigraphy).
• Electroencephalography.
• Echoencephalography.
• CT scan
• Nuclear magnetic resonance.

Thus, the diagnosis of pyelonephritis in children is established based on a combination of the following criteria [6].

• Symptoms of intoxication.
• Pain syndrome.
• Changes in urinary sediment: leukocyturia of the neutrophilic type (more than 50% neutrophils), bacteriuria (more than 100 thousand microbial bodies in 1 ml of urine), proteinuria (less than 1 g/l of protein).
• Violation of the functional state of the kidneys of the tubulointerstitial type: decrease in urine osmolarity less than 800 mOsmol/l with blood osmolarity less than 275 mOsmol/l, decrease in the relative density of urine and indicators of acido- and amoniogenesis, increase in the level of β2-microglobulin in the blood plasma more than 2.5 mg/l and in urine - above 0.2 mg/l.
• Asymmetry of contrasting of the maxillary joint, coarsening and deformation of the arches of the cups, pyelectasis.
• Lengthening of the secretory and excretory segments of renograms, their asymmetry.

Additional criteria may include:

• Increased ESR (more than 15 mm/h).
• Leukocytosis (more than 9Ё109/l) with a shift to the left.
• Increased titers of antibacterial antibodies (1:160 or more), disimmunoglobulinemia, increased number of circulating immune complexes.
• Increased CRP levels (above 20 mcg/ml), hyper-γ- and hyper-α2-globulinemia.

Complications of pyelonephritis are associated with the development of purulent processes and progressive dysfunction of the tubules, leading to the development of chronic renal failure in chronic pyelonephritis.

Complications of pyelonephritis:

• nephrogenic arterial hypertension;
• hydronephrotic transformation;
• pyelonephritic wrinkled kidney, uremia;
• purulent complications (apostematous nephritis, abscesses, paranephritis, urosepsis);
• bacteremic shock.

Pyelonephritis must be differentiated from chronic cystitis, interstitial nephritis, acute glomerulonephritis with isolated urinary syndrome, chronic glomerulonephritis, kidney tuberculosis, etc. Often in pediatric practice, pyelonephritis is diagnosed as an “acute abdomen,” intestinal and respiratory infections, pneumonia, and sepsis.

Treatment of pyelonephritis

Treatment of pyelonephritis involves not only antibacterial, pathogenetic and symptomatic therapy, but also the organization of the correct regimen and nutrition of the sick child.

The issue of hospitalization is decided depending on the severity of the child’s condition, the risk of complications and the social conditions of the family. In the active stage of the disease, in the presence of fever and pain, bed rest is prescribed for 5–7 days.

Dietary restrictions are aimed at reducing the load on the tubular transport systems and correcting metabolic disorders. In the active stage, table No. 5 according to Pevzner is used without salt restriction, but with an increased drinking regime, 50% more than the age norm. The amount of salt and liquid is limited only if kidney function is impaired. It is recommended to alternate protein and plant foods. Products containing extractives and essential oils, fried, spicy, fatty foods are excluded. Detected metabolic disorders require special corrective diets.

The basis of drug treatment of pyelonephritis is antibacterial therapy, which is based on the following principles [6]:

• Before starting treatment, a urine culture is necessary (later treatment is changed based on the culture results);
• exclude and, if possible, eliminate factors contributing to infection;
• improvement of the condition does not mean the disappearance of bacteriuria;
• treatment results are regarded as failure if there is no improvement and/or persistence of bacteriuria;
• primary lower urinary tract infections usually respond to short courses of antimicrobial therapy; upper urinary tract - require long-term therapy;
• early relapses (up to 2 weeks) represent a recurrent infection and are caused either by the survival of the pathogen in the upper urinary tract or by ongoing seeding from the intestine. Late relapses are almost always re-infection;
• pathogens of community-acquired urinary tract infections are usually sensitive to antibiotics;
• frequent relapses, instrumental interventions on the urinary tract, recent hospitalization make one suspect an infection caused by resistant pathogens.

Therapy for pyelonephritis includes several stages: 1) suppression of the active microbial inflammatory process using an etiological approach; 2) pathogenetic treatment against the background of subsiding of the process using antioxidant protection and immunocorrection; 3) anti-relapse treatment. Therapy for acute pyelonephritis, as a rule, is limited to the first two stages; for chronic pyelonephritis, all three stages of treatment are necessary [6].

The stage of suppressing the activity of the microbial inflammatory process. Conventionally, this stage can be divided into two periods.

The first is aimed at eliminating the pathogen before obtaining urine culture results and includes the appointment of initial (empirical) antibacterial therapy, diuretic therapy (for non-obstructive variants), infusion-corrective therapy for severe endogenous intoxication syndrome and hemodynamic disorders.

The second (etiotropic) period consists of correcting antibacterial therapy taking into account the results of urine culture and determining the sensitivity of the microorganism to antibiotics.

When choosing antibacterial drugs, it is necessary to consider that:

• the drug must be active against the most common pathogens of urinary tract infections;
• must not be nephrotoxic;
• should create high concentrations at the site of inflammation (urine, interstitium);
• should have a predominantly bactericidal effect;
• must be active at the pH values ​​of the patient’s urine (Table 2);
• when combining several drugs, synergism should be observed [5, 6].

The duration of antibacterial therapy should be optimal, ensuring complete suppression of pathogen activity. Thus, its duration is usually about 4 weeks in the hospital with a change of antibiotic every 7-10 days (or replacement with a uroseptic).

Initial antibiotic therapy is prescribed empirically, based on the most likely causative agents of infection. If there is no clinical and laboratory effect, the antibiotic must be changed after 2–3 days.

In case of manifest severe and moderate pyelonephritis, drugs are administered mainly parenterally (intravenously or intramuscularly) in a hospital setting.

We list some antibiotics used in the initial treatment of pyelonephritis:

• semisynthetic penicillins in combination with β-lactomase inhibitors - amoxicillin and clavulanic acid: augmentin - 25-50 mg/kg/day, orally - 10-14 days; amoxiclav - 20-40 mc/kg/day, orally - 10-14 days;
• 2nd generation cephalosporins: cefuroxime (zinacef, ketocef, cefurabol), cefamandol (mandol, cefamabol) - 80-160 mg/kg/day, intravenously, intramuscularly - 4 times a day - 7-10 days;
• 3rd generation cephalosporins: cefotaxime (claforan, clafobrine), ceftazidime (Fortum, Vicef), ceftizoxime (epocelin) - 75-200 mg/kg/day, intravenously, intramuscularly - 3-4 times a day - 7-10 days; cefoperazone (cephobid, cefoperabol), ceftriaxone (rocephin, ceftriabol) - 50-100 mg/kg/day, intravenously, intramuscularly - 2 times a day - 7-10 days;
• aminoglycosides: gentamicin (gentamicin sulfate) - 3.0-7.5 mg/kg/day, intravenously, intramuscularly - 3 times a day - 5-7 days; amikacin (amicin, lykacin) - 15-30 mg/kg/day, intravenously, intramuscularly - 2 times a day - 5-7 days.

During the period of subsidence of activity, antibacterial drugs are administered mainly orally, while “step therapy” is possible, when the same drug that was administered parenterally or a drug of the same group is given orally [5]. The most commonly used during this period are:

• semisynthetic penicillins in combination with β-lactomase inhibitors: amoxicillin and clavulanic acid (Augmentin, amoxiclav);
• 2nd generation cephalosporins: cefaclor (Ceclor, Vercef) - 20–40 mg/kg/day;
• 3rd generation cephalosporins: ceftibuten (cedex) - 9 mg/kg/day, once;
• nitrofuran derivatives: nitrofurantoin (furadonin) - 5–7 mg/kg/day;
• quinolone derivatives (non-fluorinated): nalidixic acid (negram, nevigramon) - 60 mg/kg/day; pipemidic acid (palin, pimidel) - 0.4–0.8 g/day; nitroxoline (5-NOK, 5-nitrox) - 10 mg/kg/day;
• sulfamethoxazole and trimethoprim (cotrimoxazole, biseptol) - 4-6 mg/kg/day for trimethoprim.

In severe septic conditions, microbial associations, multiresistance of microflora to antibiotics, when affecting intracellular microorganisms, as well as to expand the spectrum of antimicrobial action in the absence of culture results, combination antibacterial therapy is used. In this case, bactericidal antibiotics are combined with bactericidal, bacteriostatic with bacteriostatic antibiotics. Some antibiotics are bactericidal against some microorganisms and bacteriostatic against others.

Bactericidal drugs include: penicillins, cephalosporins, aminoglycosides, polymyxins, etc.

Bacteriostatic drugs include: macrolides, tetracyclines, chloramphenicol, lincomycin, etc.

Potentiate the action of each other (synergists): penicillins and aminoglycosides; cephalosporins and penicillins; cephalosporins and aminoglycosides.

Antagonists are: penicillins and chloramphenicol; penicillins and tetracyclines; macrolides and chloramphenicol.

From the point of view of nephrotoxicity, erythromycin, drugs of the penicillin group and cephalosporins are non-toxic or low-toxic; moderately toxic - gentamicin, tetracycline, etc.; Kanamycin, monomycin, polymyxin, etc. have pronounced nephrotoxicity.

Risk factors for nephrotoxicity of aminoglycosides are: duration of use for more than 11 days, maximum concentration above 10 μg/ml, combination with cephalosporins, liver disease, high creatinine levels [6].

After a course of antibiotic therapy, treatment should be continued with uroantiseptics.

Nalidixic acid preparations (nevigramon, negram) are prescribed to children over 2 years of age. These agents are bacteriostatics or bactericides, depending on the dose, against gram-negative flora. They should not be prescribed simultaneously with nitrofurans, which have an antagonistic effect. The course of treatment is 7–10 days.

Gramurin, a derivative of oxolinic acid, has a wide spectrum of action on gram-negative and gram-positive microorganisms. It is used in children aged 2 years and over for a course of 7–10 days.

Pipemidic acid (palin, pimidel) has an effect on most gram-negative bacteria and staphylococci. Prescribed in a short course (3–7 days).

Nitroxoline (5-NOK) and nitrofurans are drugs with broad bactericidal action.

The reserve drug is ofloxacin (Tarivid, Zanocin). It has a wide spectrum of action, including on intracellular flora. It is prescribed to children only if other uroseptics are ineffective.

The use of biseptol is possible only as an anti-relapse agent in the latent course of pyelonephritis and in the absence of obstruction in the urinary tract.

In the first days of the disease, against the background of increased water load, fast-acting diuretics (furosemide, veroshpiron) are used, which increase renal blood flow, ensure the elimination of microorganisms and inflammatory products and reduce swelling of the interstitial tissue of the kidneys. The composition and volume of infusion therapy depend on the severity of the intoxication syndrome, the patient's condition, hemostasis, diuresis and other kidney functions.

The stage of pathogenetic therapy begins when the microbial inflammatory process subsides against the background of antibacterial drugs. On average, this occurs on the 5–7th day from the onset of the disease. Pathogenetic therapy includes anti-inflammatory, antioxidant, immunocorrective and anti-sclerotic therapy [6].

A combination with anti-inflammatory drugs is used to suppress inflammatory activity and enhance the effect of antibacterial therapy. It is recommended to take non-steroidal anti-inflammatory drugs - ortofen, voltaren, surgam. The course of treatment is 10–14 days. The use of indomethacin in pediatric practice is not recommended due to a possible deterioration in the blood supply to the kidneys, decreased glomerular filtration, water and electrolyte retention, and necrosis of the renal papillae.

Desensitizing agents (tavegil, suprastin, claritin, etc.) are prescribed for acute or chronic pyelonephritis in order to relieve the allergic component of the infectious process, as well as when the patient develops sensitization to bacterial antigens.

The complex therapy for pyelonephritis includes drugs with antioxidant and antiradical activity: tocopherol acetate (1–2 mg/kg/day for 4 weeks), unithiol (0.1 mg/kg/day intramuscularly once, for 7–10 days), b-carotene (1 drop per year of life, 1 time per day for 4 weeks), etc. Among the drugs that improve kidney microcirculation, trental, cinnarizine, and aminophylline are prescribed.

Immunocorrective therapy for pyelonephritis is prescribed strictly according to indications [4]:

• infancy;
• severe variants of kidney damage (purulent lesions; aggravated by multiple organ failure syndrome; obstructive pyelonephritis against the background of reflux, hydronephrosis, megaureter, etc.);
• long-term (more than 1 month) or recurrent course;
• intolerance to antibiotics;
• features of the microflora (mixed flora; flora multiresistant to antibiotics; unusual nature of the flora - Proteus, Pseudomonas, Enterobacter, etc.).

The prescription of immunocorrective therapy is made only after agreement with an immunologist and should include immunological monitoring, relative “selectivity” of the prescription, a short or intermittent course and strict adherence to the dosage and regimen of drug administration.

Immunal, sodium nucleate, t-activin, levamisole hydrochloride, lycopid, immunofan, reaferon, leukinferon, viferon, cycloferon, myelopid, lysozyme are used as immunotropic agents for pyelonephritis and urinary tract infections in children.

If patients have signs of sclerosis of the renal parenchyma, it is necessary to include in the treatment complex drugs that have an anti-sclerotic effect (delagil) for a course of 4-6 weeks.

During the period of remission, a necessary continuation of treatment is herbal medicine (collections of St. John's wort, lingonberry leaves, nettles, corn silk, bearberry, rose hips, birch buds, yarrow, sage, chamomile in combinations).

Anti-relapse therapy for pyelonephritis involves long-term treatment with antibacterial drugs in small doses and is carried out, as a rule, in an outpatient setting.

For this purpose, use: biseptol at the rate of 2 mg/kg for trimethoprim and 10 mg/kg for sulfamethoxazole 1 time per day for 4 weeks (use with caution in case of obstructive pyelonephritis); furagin at the rate of 6–8 mg/kg for 2 weeks, then if urine tests are normal, switch to 1/2–1/3 doses for 4–8 weeks; prescribing one of the drugs pipemidic acid, nalidixic acid or 8-hydroxyquinoline every month for 10 days in usual dosages for 3–4 months.

For the treatment of frequently recurrent pyelonephritis, a “duplicate” regimen can be used: nitroxoline at a dose of 2 mg/kg in the morning and biseptol at a dose of 2–10 mg/kg in the evening.

At any stage of treatment of secondary pyelonephritis, it is necessary to take into account its nature and the functional state of the kidneys. Treatment of obstructive pyelonephritis should be carried out jointly with a urologist and pediatric surgeon. In this case, the decision to prescribe diuretics and increase the water load should be made taking into account the nature of the obstruction. The issue of surgical treatment must be resolved in a timely manner, since in the presence of obstruction of urine flow at any level of the urinary system, the prerequisites for the development of relapse of the disease remain.

The treatment of dysmetabolic pyelonephritis should include an appropriate dietary regimen and pharmacological treatment.

With the development of renal failure, it is necessary to adjust the doses of medications in accordance with the degree of decrease in glomerular filtration.

Dynamic observation of children suffering from pyelonephritis suggests the following [6, 9].

• Frequency of examination by a nephrologist: during exacerbation - once every 10 days; during remission during treatment - once a month; remission after completion of treatment for the first 3 years - once every 3 months; remission in subsequent years until the age of 15 years - 1-2 times a year, then observation is transferred to therapists.
• Clinical and laboratory tests: general urine analysis - at least once every 1 month and against the background of acute respiratory viral infections; biochemical urine analysis - once every 3-6 months; Ultrasound of the kidneys - once every 6 months. According to indications - cystoscopy, cystography and intravenous urography.

Removal from the dispensary register of a child who has suffered acute pyelonephritis is possible if clinical and laboratory remission is maintained without therapeutic measures (antibiotics and uroseptics) for more than 5 years after a full clinical and laboratory examination. Patients with chronic pyelonephritis are observed before transfer to the adult network.

Literature

1. Borisov I. A. Pyelonephritis//In the book. "Nephrology" / ed. I. E. Tareeva. M.: Medicine, 2000. pp. 383–399.
2. Vozianov A.F., Maydannik V.G., Bidny V.G., Bagdasarova I.V. Fundamentals of childhood nephrology. Kyiv: Book Plus, 2002. pp. 22–100.
3. Ignatova M. S., Veltishchev Yu. E. Pediatric nephrology. L.: Medicine, 1989. 432 p.
4. Kirillov V.I. Immunocorrective therapy of urinary system infections in children//In the book. "Nephrology" / ed. M. S. Ignatova: a guide to pharmacotherapy in pediatrics and pediatric surgery (edited by A. D. Tsaregorodtsev, V. A. Tabolin). M.: Medpraktika-M, 2003. T. 3. P. 171–179.
5. Korovina N. A., Zakharova I. N., Mumladze E. B., Zaplatnikov A. L. Rational choice of antimicrobial therapy for urinary system infections in children // In the book. "Nephrology" / ed. M. S. Ignatova: a guide to pharmacotherapy in pediatrics and pediatric surgery (edited by A. D. Tsaregorodtsev, V. A. Tabolin). M.: Medpraktika-M, 2003. T. 3. P. 119–170.
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A. V. Malkoch , Candidate of Medical Sciences V. A. Gavrilova , Doctor of Medical Sciences Yu. B. Yurasova , Candidate of Medical Sciences Russian State Medical University, Russian Children's Clinical Hospital, Moscow

Chronic renal failure

Pathology develops if the acute form is not treated. Chronic renal failure is a condition in which anemia is observed, phosphorus-calcium metabolism is disrupted, and blood pressure increases. The cause of chronic renal failure in children can be poisoning with drugs and heavy metals, untreated infections and diseases of the urinary system:

• pyelonephritis;
• scleroderma;
• arterial stenosis;
• amyloidosis;
• hereditary nephritis;
• tumors, kidney stones.

In children under 3 years of age, the development of the disease is often caused by abnormalities in the development of the urinary tract, heredity, and renal tissue dysplasia.

The causes of chronic renal failure in children over 10 years of age are acquired diseases: organ damage due to tuberculosis, diabetes mellitus. The risk group includes children with intrauterine development disorders and obstructive diseases. Source: T.I. Razdolkina Features of chronic renal failure in children // Difficult Patient, 2013, No. 2-3, v. 11, pp. 16-20

Stages of development of chronic renal failure

• Compensated – no complaints.
• Subcompensated – accompanied by increased thirst, decreased appetite, and disruption of the gastrointestinal tract. CRF manifests itself in growth retardation, severe intestinal infections, dry skin and peeling.
• Decompensated – a noticeable decrease in urine volume. Signs include poor appetite and nausea. In children, curvature of the legs is noticeable.
• Terminal – damage to organs and systems, requiring transplantation or dialysis. Swelling of the face and lower extremities, headaches, lack of appetite, decreased vision, shortness of breath, itchy skin. There is a sharp lag in growth.

Features of the development of the excretory system in children

At birth, the kidneys weigh only about 12 grams. Considering that in an adult the mass of this organ reaches 150 grams, the kidney increases in size by about 10 times, and the growth of the organ continues until approximately 30 years of age. In the first year of life, the urinary tract actively grows, the fatty capsule of the kidney is formed, and the thickness of the walls of the kidney vessels changes.

Children, compared to adults (in terms of body weight and volume), produce more urine and urinate more frequently. This is due to age-related characteristics of water metabolism, as well as the high content of carbohydrates in the diet of children. The reaction of urine (more acidic or more alkaline) also depends on the characteristics of the diet - consuming a large amount of protein makes the urine reaction acidic, a large amount of carbohydrates makes the urine reaction more alkaline. In addition, children normally have protein in their urine (adults should not have protein in their urine).

Treatment of the disease

In the acute form, when there is severe intoxication of the body, emergency medical care is necessary. It is necessary to call an ambulance for hospitalization and detoxification measures. Doctors wash the stomach and clean the esophagus with enterosorbents. In case of a threat to life, hemosorption or hemodialysis is performed. Treatment of chronic renal failure in children is carried out to restore kidney function and slow down pathological processes. The course is compiled individually, taking into account the cause and condition of the patient. Depending on the form of the disease and the clinical picture, medication or active treatment is prescribed. No one can answer the question of whether a child will outgrow chronic renal failure; it is necessary to follow the instructions and monitor the state of glomerular filtration.

Conservative methods

Therapy includes:

• low protein, salt-free diet;
• diuretics to increase urination;
• hormones;
• stimulants to relieve anemia;
• medications to regulate blood pressure to prevent the development of heart disease; medications to reduce stomach acidity;
• vitamin D and calcium to prevent renal degeneration.

Active methods

If medications do not help, therapy using special devices is indicated to prevent relapses and maintain vital functions.

• Hemodialysis is hardware blood purification using an “artificial kidney” device. During the procedure, toxins are removed and the water-salt balance is restored. A visit to a dialysis center is required.
• Peritoneal dialysis purifies the blood and restores balance by filtering it through the abdomen. The procedure is carried out at home.
• Kidney transplant. The operation increases the duration and improves the quality of life.

Treatment methods

Urolithiasis in children is treated* both conservatively (with the help of medications) and surgically.

• Conservative treatment.
  It is aimed either at dissolving the stone or at accelerating its removal naturally through urine. For this purpose, special medications are prescribed for 7-10 days. This method is effective for small stones.
• Surgical treatment.
  It is used when stones are larger than 5 millimeters or when conservative therapy is ineffective. Performed under general anesthesia.

There are three main methods of surgical lithotripsy - crushing stones using various types of directed energy (ultrasound, laser) and subsequent removal of their fragments from the body.

• 1. Remote lithotripsy.
  Today it is the most advanced technique. It is carried out using a complex device (lithotripter) without penetrating the child’s body. A focused ultrasound pulse is directed at the stone and acts on it until it is completely destroyed.
• Morozov Children's City Clinical Hospital was the first in the structure of children's urban healthcare to begin using a remote lithotripter. This high-tech equipment allows you to destroy stones in the most gentle way - without direct intervention in the body.
• 2. Intraluminal lithotripsy.
  The stone is also affected by ultrasound or laser, but is “approached” through natural means: a special instrument equipped with a video camera is inserted into the urethra.
• 3. Percutaneous lithotripsy.
  As the name suggests, access is through a small puncture of the skin in the lumbar region. The operation is carried out under the control of an X-ray machine and the introduction of contrast agents. Used for particularly large kidney stones, the particles of which cannot be excreted naturally in the urine after crushing.

*Please note that the decision to choose one or another treatment method is made by doctors, depending on the individual indications and contraindications of a particular patient.

Which treatment method is considered the most optimal?

To call any one treatment method universal today would be a mistake.
The fact is that the urinary system is a complex and extended structure. It contains the upper and lower urinary tract. Access to each of the departments of this system may be different. Therefore, we are limited in choosing any one method for kidney disease in children. Each case is individual. Fortunately, gone are the days when they resorted to open surgery - abdominal surgery with an incision in the abdominal cavity and subsequent suturing. The Morozov Hospital today has the entire necessary arsenal of methods and equipment for minimally invasive (gentle) therapy of urolithiasis in children. Roman Viktorovich Surov

PhD, pediatric surgeon, pediatric urologist-andrologist at Morozov Hospital, member of the European Association of Pediatric Urology.

Consequences and complications

If diagnosis is not made in a timely manner and treatment is incorrect, serious complications can occur. The development of the disease leads to a reduction in renal function, disruption of systems and organs, poisoning by metabolic products, and irreversible consequences.

Among the dangerous complications:

• risk of cardiac arrest;
• dysfunction of several body systems;
• blood poisoning;
• uremia.

If there is a pathology, the child is developmentally delayed, does not fit into the team well, and has difficulties in developing speech.

Dangerous age

From birth to 3 years. This age is the most alarming, since most of the violations occur at this time. Within three years, the baby’s body fully adapts to the environment after life in the womb. If there are any congenital anomalies, they will definitely appear.

From 5 to 7 years. A time of age-related changes, when all body systems are most vulnerable. This also applies to the urinary system.

From 14 to 18 years old. During puberty, the risk of disruption of the urinary system is quite high. And all because the hormonal background changes and the child begins to grow actively.

Heredity also plays an important role. If one of the parents suffers from pyelonephritis or has endocrine disorders, then they can also appear in children. Parents should be careful if they have kidney disease. Symptoms in children indicate that urgent action is needed.

Prevention in children

Parents' attentive attitude to the appearance of the first signs allows the disease to be completely cured without consequences. Clinical recommendations for the prevention of chronic renal failure in children:

• treat and follow-up kidney diseases (pyelonephritis);
• Healthy food;
• do not take medications unreasonably;
• do not abuse folk remedies.

If you suspect a pathology, you should immediately consult a doctor. To prevent congenital diseases, the expectant mother should adhere to a healthy diet and lifestyle.

Sources:

1. O.I. Andriyanova, F.K. Manerov, Yu.A. Churlyaev, I.G. Hamin. Causes and treatment of acute renal failure in children // General resuscitation, 2007, III, 4, pp. 70-75.
2. T.I. Razdolkina. Features of chronic renal failure in children // Difficult Patient, 2013, No. 2-3, v. 11, pp. 16-20.
3. Iseki K., Ikemiya Y, Iseki C., Takishita S. Proteinuria and the risk of developing end-stage renal disease // Kidney Int. 2003; 63:1468-1473

The information in this article is provided for reference purposes and does not replace advice from a qualified professional. Don't self-medicate! At the first signs of illness, you should consult a doctor.

Symptoms of urolithiasis in children

In children, the symptoms of urolithiasis depend on which part of the urinary system the stone is “stuck” in. The most dangerous situation is when a stone closes the lumen of the ureter, making the outflow of urine impossible. In this case, the child complains of acute pain, cannot urinate on his own, and may even lose consciousness.

Signs of classic renal colic, both in children and adults, are acute pain, difficulty urinating and blood in the urine.

In young children, parents should be concerned about fever, vomiting, refusal to eat, and restless behavior.

Very often, the disease is generally asymptomatic for a long period of time and only errors in the analysis of the child’s urine can indicate it.

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Symptoms

There are a number of signs that parents cannot miss. Below we list the main symptoms of kidney problems in children:

• unpleasant sensations in the lumbar region, of varying intensity - from nagging to acute;
• changes in the appearance of urine;
• rise in temperature without signs of respiratory infection;
• swelling of the face in the morning;
• noticeable swelling under the eyes;
• weakness and fatigue;
• dry mouth and constant thirst.

It also happens that the pathology does not show itself as symptoms.

For kids who still cannot explain their feelings, there are signs. In addition to changes in urine, the following changes will become noticeable:

• the belly will increase;
• the stream of urine may become weaker (we are talking about boys, although with phimosis this is normal).

Slightly older children may point to their stomach, urinate frequently, or vice versa - very rarely. The baby may also refuse to go to the toilet. If previously the child produced a normal amount of urine, during illness it decreases significantly.

As we have already said, any ailment can lead to a serious problem - kidney failure.

Features of the treatment of kidney diseases in children with anomalies

In case of anomalies in the number of kidneys, with the exception of agenesis (underdevelopment of the organ), the outcome of which is unfavorable, symptomatic treatment, diet selection and active therapy for possible inflammatory diseases are carried out, since with kidney anomalies conditions are often created for obstructive disorders, reflux (reverse reflux of urine from the bladder into the kidney), urinary tract infections. This form of anomaly is often complicated by renal arterial hypertension, for which lifelong antihypertensive therapy is prescribed. In case of severe dysfunction of the organ, kidney transplantation is possible.

Abnormalities in the position of the kidneys (positional) are more common. Such children are registered at the dispensary, they are prescribed courses of massage and wearing bandages (according to indications) and prevention of complications such as hydronephrosis and urolithiasis (KD), and if persistent pain occurs, surgical treatment is used.

Anomalies of shape (fusion) occur in 15-20% of all honorary anomalies. There are symmetrical (horseshoe-shaped) and asymmetrical (S- and L-shaped fusions). Treatment is conservative and observation. Surgical interventions are performed in case of severe hydronephrosis (obstruction of the urethral segment), severe pain syndrome, with the development of urolithiasis, tumors.

With anomalies of the pyelocaliceal system, renal function is not impaired. These anomalies do not require special treatment, unless they are complicated by some pathological process, usually nephrolithiasis (NPD).

Anomalies in the development of the ureters are the main element of the anomaly of the kidney itself. Treatment is only surgical.

Anomalies of bladder development are more common in boys. Agenesis (underdevelopment) of the bladder is an extremely rare disease, often combined with other defects of the urinary system. Children with this pathology are not viable.

The most important direction of modern pediatric urology is the correction of congenital anomalies of the genitourinary system, primarily congenital defects in the development of the urethra and bladder. And if a couple of decades ago these defects required long-term multi-stage treatment, today urologists are increasingly striving to operate on such children in one stage. Of these anomalies of the genitourinary system, first of all, it is worth noting such congenital diseases as hypospadias (underdevelopment of the final part of the urethra and epispadias (partial or complete splitting of the anterior wall of the urethra), as being of great importance for the full development of the child. Treatment of this pathology requires various plastic surgeries.In these surgeries, replacement tissue is taken from the smallest patient.

I would like to dwell on one of the most common complications of congenital anomalies of the urinary tract (in the ureteropelvic segment) - hydronephrosis in children, since its frequency is 3 cases per 1000 newborns. Hydronephrosis of the kidneys is an increasing expansion of the renal calyces and pelvis with atrophy of the renal parenchyma (kidney lining), caused by a chronic violation of the outflow of urine from the kidney. The development of hydronephrosis is caused by any process (both in the urinary system and outside it - stones, tumors, etc.) that causes an obstruction to the outflow of urine. As a result of increasing intrapelvic pressure, atrophy (a decrease in the mass and volume of the kidneys, accompanied by a weakening/cessation of their function) of the renal parenchyma and muscle fibers of the wall of the urinary tract occurs and kidney function decreases. However, in our country there is a well-established diagnostic system using the screening method - ultrasound (sensitivity of the method is 65-98%), incl. and in utero. Dynamic monitoring of children who were diagnosed with hydronephrosis before birth is necessary, because in 10% of these babies this diagnosis is not confirmed in the first days of life. If the disease develops at an older age, then one of its symptoms is the presence of a tumor-like formation in the baby’s abdomen, usually detected by parents when bathing the child. Early detected hydronephrosis determines the success of surgical treatment and the preservation of kidney function. Over the past 5 years, a lot of research has been carried out, and vast positive experience has been accumulated in performing ureteroplasty operations in children, optimal methods of postoperative drainage of the urinary tract, etc. have been found, which leads to good treatment results.

An equally important congenital anomaly is anomalies of the bladder. In this case, exstrophy of the bladder deserves special attention. In this case, there is an absence of the anterior wall of the bladder, as well as the corresponding part of the abdominal wall. Treatment of such an anomaly also involves performing plastic corrective surgeries that correct the congenital defect.

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Congenital kidney diseases

In recent years, parents and doctors have been concerned - the number of children with congenital and hereditary kidney diseases has increased, often complicated by the layering of infectious and inflammatory processes in the organs of the urinary system (UC) and being the most common cause of the development of such a serious complication as chronic renal failure (CRF) in childhood.

The excretory system begins to develop from the 3rd week of pregnancy. The kidneys begin to function around the ninth week of the baby's intrauterine life. Nephrons - the structural units of the kidneys develop from 20-22 weeks. They, like all organs of the genitourinary system, are very sensitive to various kinds of damaging (teratogenic) factors. The first 2-3 months of pregnancy are considered the most dangerous in terms of the development of congenital kidney diseases, and the earlier the teratogenic effect was, the more severe the developmental defects will be, possibly incompatible with life. If a harmful factor acts at 3-4 weeks of pregnancy, then the fetus may not develop kidneys (renal agenesis); if the exposure occurred at 14-15 weeks of intrauterine development, then one can expect a violation of the structure, shape and number of elements of the renal pyelocaliceal system, but at the same time, in general, the genitourinary system will be formed.

Causes of kidney disease in children

Congenital diseases of the urinary system are those diseases that exist from the birth of a child and are the result of disruption of the development processes of the embryo. In addition, this group of diseases also includes congenital disorders of the membrane transport of various substances in the renal tubules. There are congenital nephropathies (diseases of the kidney itself) and uropathy (damage to the urinary tract).

By their origin, congenital kidney diseases can be acquired in nature (developmental defects resulting from the influence of harmful factors directly on the developing embryo without damage to hereditary structures). Violations of fetal development are provoked by unhealthy environmental conditions: radiation, excessive gas pollution, etc. Unfortunately, not all expectant mothers still understand the destructive consequences of smoking, alcoholism and drug addiction on the health of the baby. The occurrence of abnormalities in the development of the kidneys and other genitourinary organs is influenced by hormonal disorders and various infectious diseases of the pelvic organs suffered by a woman at different stages of pregnancy. Doctors note a high risk of developmental disorders in the fetus in expectant mothers who have had colds in early pregnancy, accompanied by high fever (38°C and above). A pregnant woman needs to remember that it is unacceptable to use medications without consulting a doctor who is not convinced of the safety of the medicine for the unborn baby.

The second large group of congenital kidney diseases is based on hereditary pathology (as a result of mutations of genes or chromosomes).

Let's consider anatomical anomalies of the organs of the urinary system of an acquired nature.

Nephrologists have proposed the following classification of congenital nephropathies and uropathy with anatomical anomalies of the urinary system (according to M. S. Ignatova and A. V. Papayan):

1. anatomical abnormalities of the kidneys:

• quantitative (agenesis - absence of an organ, aplasia - underdevelopment of an organ and its functions, additional kidneys);
• positional (dystopia - incorrect position of an organ in space, nephroptosis - prolapse of the kidneys, rotation - rotation of an organ in space);
• shape anomalies (horseshoe-shaped, S-, L-shaped kidneys);

• anomalies of the pyelocaliceal system (megacalycosis - an increase in the volume of the renal calyces, calyceal diverticulum - a congenital protrusion of the wall of the renal calyces in the shape of a bag);
• ureteral abnormalities:
• quantity anomalies (agenesis, doubling);
• positional anomalies (ectopia - a developmental anomaly in which the mouth of the ureter is located not in the bladder, but in the urethra/vagina/on the surface of the skin of the perineum, retrocaval ureter
• location of the ureter behind the inferior vena cava);
• anomalies of structure and shape (hydroureter - accumulation of fluid in the dilated ureter due to the presence of obstacles impeding the outflow of urine, diverticulum
• congenital bladder wall in the form of a bag, dilatation
• abnormal expansion of the organ lumen);

• quantity anomalies (agenesis, doubling);
• anomalies of position (exstrophy - the absence of the lower part of the anterior abdominal wall and the body of the bladder, and the defect of the abdominal wall is replaced by the posterior wall of the bladder (the area of ​​the vesical triangle) with gaping ureteral openings on it);
• anomalies of structure and shape (diverticulum, megacystis - an excessively enlarged bladder; usually combined with hypertrophy of its walls, persistent urachus
• cleft urachus (umbilical sinus)
• intrauterine urinary duct in the navel area);

• quantity anomalies (agenesis, doubling);
• positional anomalies (urethral valve, hypospadias - absence of the final part of the male urethra with the localization of its external opening in an unusual place, epispadias
• complete or partial obstruction of the anterior wall of the urethra);

• arterial abnormalities;
• vein abnormalities;
• arteriovenous fistulas;
• abnormalities of lymphatic vessels;

• abnormal development of the penis;
• abnormalities of testicular development;