Chronic pyelonephritis is diagnosed if. Chronic pyelonephritis: causes, clinical picture, diagnosis, treatment. Folk remedies for treatment at home

Pyelonephritis is an acute or chronic kidney disease that develops as a result of the influence of certain causes (factors) on the kidney that lead to inflammation of one of its structures, called the pyelocaliceal system (the structure of the kidney in which urine accumulates and is excreted) and adjacent to this structure, tissue (parenchyma), with subsequent dysfunction of the affected kidney.

The definition of "Pyelonephritis" comes from the Greek words ( pyelos- translated as, pelvis, and nephros-bud). Inflammation of the kidney structures occurs in turn or simultaneously, it depends on the cause of pyelonephritis, it can be unilateral or bilateral. Acute pyelonephritis appears suddenly, with severe symptoms (pain in the lumbar region, fever up to 39 0 C, nausea, vomiting, difficulty urinating), with proper treatment after 10-20 days, the patient fully recovers.

Chronic pyelonephritis is characterized by exacerbations (most often in the cold season) and remissions (symptoms subside). Its symptoms are mild, most often it develops as a complication of acute pyelonephritis. Often chronic pyelonephritis is associated with any other disease of the urinary system (chronic cystitis, urolithiasis, abnormalities of the urinary system, prostate adenoma and others).

Women, especially young and middle-aged women, get the disease more often than men, approximately in a ratio of 6:1, this is due to the anatomical features of the genital organs, the onset of sexual activity, and pregnancy. Men more often develop pyelonephritis at an older age; this is most often associated with the presence of prostate adenoma. Children also get sick, more often at an early age (up to 5-7 years), compared to older children, this is due to the body’s low resistance to various infections.

Kidney anatomy

The kidney is a paired organ, bean-shaped, dark brown in color, located in the lumbar region, on either side of the spine.

The weight of one kidney is 120 - 200 g. The tissue of each kidney consists of the medulla (in the shape of pyramids), located in the center, and the cortex, located along the periphery of the kidney. The tops of the pyramids merge in 2-3 pieces, forming renal papillae, which are covered by funnel-shaped formations (small renal calyces, on average 8-9 pieces), which in turn merge in 2-3 pieces, forming large renal calyces (on average 2-4 in one kidney). Subsequently, the large renal calyces pass into one large renal pelvis (a funnel-shaped cavity in the kidney), which in turn passes into the next organ of the urinary system, called the ureter. From the ureter, urine flows into the bladder (a reservoir for collecting urine), and from it through the urethra to the outside.

Causes and risk factors in the development of pyelonephritis

Symptoms of pyelonephritis

• burning and pain during urination, due to inflammation in the urinary tract;
• the need to urinate more frequently than usual, in small portions;
• beer-colored urine (dark and cloudy) is the result of the presence of a large number of bacteria in the urine,
• unpleasant smell of urine,
• often the presence of blood in the urine (stagnation of blood in the vessels, and the release of red blood cells from the vessels into the surrounding inflamed tissues).

1. Pasternatsky's symptom is positive - when a light blow is applied to the lumbar region with the edge of the palm, pain appears.
2. Swelling, formed in the chronic form of pyelonephritis, in advanced cases (lack of treatment), often appears on the face (under the eyes), legs, or other parts of the body. Swelling appears in the morning, soft, dough-like consistency, symmetrical (the same size on the left and right sides of the body).

Diagnosis of pyelonephritis

Indicators of general urine analysis for pyelonephritis:

• High level of leukocytes (normally in men there are 0-3 leukocytes in the field of view, in women up to 0-6);
• Bacteria in urine >100,000 per ml; The excreted urine is normal and must be sterile, but when collecting it, hygienic conditions are often not observed, so the presence of bacteria up to 100,000 is allowed;
• Urine density
• Urine pH is alkaline (normally acidic);
• The presence of protein, glucose (normally they are absent).

Urinalysis according to Nechiporenko:

• Leukocytes are elevated (normally up to 2000/ml);
• Red blood cells are elevated (normally up to 1000/ml);
• Presence of cylinders (normally they are absent).

Kidney ultrasound: is the most reliable method for determining the presence of pyelonephritis. Determines different sizes of kidneys, a decrease in the size of the affected kidney, deformation of the collecting system, identification of a stone or tumor if present.

Excretory urography, is also a reliable method for detecting pyelonephritis, but compared to ultrasound, it is possible to visualize the urinary tract (ureter, bladder), and if there is a blockage (stone, tumor), determine its level.

CT scan, is the method of choice, using this method you can assess the degree of damage to the kidney tissue and identify if complications are present (for example, the spread of the inflammatory process to neighboring organs)

Treatment of pyelonephritis

Drug treatment of pyelonephritis

1. Antibiotics, prescribed for pyelonephritis, based on the results of a bacteriological examination of urine, the causative agent of pyelonephritis is determined and which antibiotic is sensitive (suitable) against this pathogen.

• Penicillins(Amoxicillin, Augmentin). Amoxicillin orally, 0.5 g 3 times a day;
• Cephalosporins(Cefuroxime, Ceftriaxone). Ceftriaxone intramuscularly or intravenously, 0.5-1 g 1-2 times a day;
• Aminoglycosides(Gentamicin, Tobramycin). Gentamicin intramuscularly or intravenously, 2 mg/kg 2 times a day;
• Tetracyclines (Doxycycline, 0.1 g orally 2 times a day);
• Levomycetin group(Chloramphenicol, 0.5 g orally 4 times a day).

• Sulfonamides(Urosulfan, 1 g orally 4 times a day);
• Nitrofurans(Furagin, orally 0.2 g 3 times a day);
• Quinolones(Nitroxoline, 0.1 g orally 4 times a day).

1. Diuretics: prescribed for chronic pyelonephritis (to remove excess water from the body and possible edema), and not prescribed for acute pyelonephritis. Furosemide 1 tablet 1 time per week.
2. Immunomodulators: increase the body's reactivity in case of illness, and to prevent exacerbation of chronic pyelonephritis.

• Timalin, intramuscularly 10-20 mg 1 time per day, 5 days;
• T-activin, intramuscularly 100 mcg once a day, 5 days;

1. Multivitamins , (Duovit, 1 tablet 1 time per day), Ginseng tincture – 30 drops 3 times a day, also used to improve immunity.
2. Nonsteroidal anti-inflammatory drugs (Voltaren), have an anti-inflammatory effect. Voltaren orally, 0.25 g 3 times a day, after meals.
3. To improve renal blood flow, these drugs are prescribed for chronic pyelonephritis. Chime, 0.025 g 3 times a day.

Herbal medicine for pyelonephritis

Cranberry juice has an antimicrobial effect, drink 1 glass 3 times a day.

Bearberry decoction has an antimicrobial effect, take 2 tablespoons 5 times a day.

Boil 200 g of oats in one liter of milk, drink ¼ glass 3 times a day.
Kidney collection No. 1: A decoction of a mixture (rose hips, birch leaves, yarrow, chicory root, hops), drink 100 ml 3 times a day, 20-30 minutes before meals.
It has a diuretic and antimicrobial effect.

Collection No. 2: bearberry, birch, hernia, knotweed, fennel, calendula, chamomile, mint, lingonberry. Finely chop all these herbs, add 2 tablespoons of water and boil for 20 minutes, take half a glass 4 times a day.

Chronic pyelonephritis is a chronic pathology characterized by nonspecific inflammation of kidney tissue. As a result of the progression of the pathological process, destruction of the pelvis and organ vessels is observed.

Chronic pyelonephritis is usually a consequence of a previously suffered acute form of the disease. There are cases that patients cannot remember that they had an acute attack, since this pathology can progress without a single symptom. Chronicization of the process can occur due to the following reasons:

• impaired urine excretion due to the formation of stones or due to narrowing of the urinary tract;
• inadequate therapy for the acute form of the disease;
• urine reflux;
• chronic intoxication of the body. Observed with abuse of alcoholic beverages, smoking;
• the presence of common pathologies. This includes immunodeficiency conditions, etc.;
• inflammation in organs located in close proximity to the kidneys - and so on.

It is worth noting that chronic pyelonephritis usually affects two kidneys at the same time. More often, the pathology is diagnosed in the fair sex. Chronic pyelonephritis in children rarely progresses.

Etiology

The progression of chronic pyelonephritis is provoked by infectious agents:

• Proteus;
• enterococcus

Risk factors:

• promiscuity (possible infection with dangerous microorganisms - chlamydia, gonococci, etc.);
• pregnancy. Quite often, chronic pyelonephritis is diagnosed during pregnancy, since during this period hormonal changes occur, the enlarging uterus can put pressure on the organs of the urinary system;
• disruption of the normal outflow of urine;
• disturbance of innervation of the bladder;
• burdened heredity.

Symptoms

The symptoms of chronic pyelonephritis are quite varied. It is worth noting that the course of the pathological process in the kidneys may resemble other pathologies of the urinary system, so it is important to conduct a detailed differential diagnosis.

Symptoms may vary depending on what form of the disease progresses in the patient. Clinicians distinguish 5 forms:

• latent;
• azotemic;
• anemic;
• recurrent;
• hypertensive.

Latent

For this form of pathology, the clinical picture is quite poor. The patient may only complain of progressive weakness and increased fatigue. Rarely, minor hyperthermia may occur. Pain syndrome in the area of ​​​​the projection of the kidneys, dysuria and peripheral edema are absent.

The concentrating ability of the kidneys decreases, which is reflected in the density of urine, and is manifested by polyuria. If you conduct a urine test, you can detect the presence of bacteria and leukocytes in it.

Anemic

The clinical picture is dominated by anemic symptoms:

• weakness;
• dyspnea;
• pale skin;
• There may be pain in the heart.

Changes in urine are quite scanty and cannot always be detected.

Hypertensive

The symptoms of the pathology are quite pronounced:

• dizziness;
• dyspnea;
• rapid increase in blood pressure;
• insomnia;
• In the projection of the heart, stabbing pains are felt.

Azotemic

This form of pathology progresses only at the stage of chronic renal failure. The symptoms are as follows:

• increased blood pressure;
• bowel dysfunction;
• decreased appetite;
• nausea and vomiting;
• the concentration of calcium in the blood decreases;
• muscle weakness;
• numbness of the feet and hands.

If severe renal failure is observed, the clinical picture is complemented by the following symptoms:

• lipid metabolism disorder;
• pain in joints and bones;
• secondary;
• heart rhythm disturbance;
• atrial fibrillation;
• unpleasant taste in the mouth;
• enlarged salivary glands;
• puffiness of the face.

Recurrent form

This form of pathology is characterized by alternating periods of remission and exacerbation. The patient is periodically bothered by discomfort at the site of kidney projection, chills and hyperthermia. Later, dysuric manifestations appear.

Exacerbation of chronic pyelonephritis in its symptoms resembles the clinical picture of acute inflammation. At this stage, the following symptoms appear:

• headache;
• pain in the heart area;
• increased blood pressure;
• anemic syndrome;
• decreased visual function.

If a person often experiences periods of exacerbation of the disease, this may result in the occurrence of kidney failure.

During exacerbation, the following changes are observed in the TAM:

• cylindruria;
• proteinuria;
• bacteriuria;
• microhematuria;
• leukocyturia.

In a blood test during an exacerbation, acceleration, an increase in quantity, and also are detected.

Diagnostics

Diagnosis of the disease in the acute stage presents some difficulties, since the clinical picture that appears is reminiscent of other pathologies of the urinary system. To accurately make a diagnosis, doctors use the following diagnostic techniques:

• (most informative);
• kidney x-ray;
• bacterial culture of urine;
• radioisotope renography;
• kidney biopsy.

Treatment

Treatment of chronic pyelonephritis should only be comprehensive. Conservative methods are used:

• diet therapy. The diet for chronic pyelonephritis is developed individually for each patient. It is necessary to observe it not only during treatment, but also after it;
• painkillers;
• antibiotics;
• antipyretics;
• anti-inflammatory drugs;
• antiplatelet agents. These drugs are prescribed to normalize microcirculation.

Treatment of chronic pyelonephritis is carried out in a hospital setting so that doctors can monitor the patient’s condition and, if necessary, make adjustments to the treatment plan.

Diet

Proper nutrition will help you get rid of pathology faster. The diet for chronic pyelonephritis during exacerbation excludes the use of:

• acute;
• fat;
• spicy products;
• salt.

You need to include in your diet:

• dairy products;
• fruits;
• berries.

It is also recommended to consume at least 2 liters of fluid per day. This will help eliminate infectious agents from the kidneys faster.

Prevention

To prevent the progression of chronic pyelonephritis, you must adhere to the following recommendations:

• strengthen the immune system so that the body can independently fight various infectious agents;
• promptly diagnose and fully treat acute ailments of the urinary system;
• eliminate local factors that disrupt urodynamics (cure, etc.).

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Diseases with similar symptoms:

Premenstrual syndrome is a complex of painful sensations that occur ten days before the onset of menstruation. The signs and symptoms of this disorder and their combination are individual in nature. Some female representatives may experience symptoms such as headaches, sudden changes in mood, depression or tearfulness, while others may experience pain in the mammary glands, vomiting or constant pain in the lower abdomen.

Leaking chronic pyelonephritis with alternating phases of active and latent inflammation and remission. Chronic pyelonephritis does not have such pronounced manifestations as acute pyelonephritis, and therefore it is much more dangerous.

Usually the disease occurs as a result of incompletely cured acute pyelonephritis. There may be cases when chronic pyelonephritis is almost asymptomatic. It can drag on for months and even years, gradually destroying the kidneys and rendering them inoperable. The patient has no symptoms of the disease, well, sometimes his lower back ache a little, and he often has a headache for a long time. People attribute all this to the weather or physical activity. Fluctuations in blood pressure do not alarm them either. Many people simply try to knock it down on their own, without consulting a doctor.

There are the following forms of chronic pyelonephritis.

By occurrence:

Primary - not associated with any

urological disease,

Secondary - developing due to damage to the urinary tract.

According to the localization of the inflammatory process:

Unilateral,

Bilateral,

Total - affecting the entire kidney,

Segmental - affecting part of the kidney.

According to the clinical picture:

Latent,

Recurrent,

Hypertensive,

Anemic,

Azotemic,

Hematuric.

In latent form Chronic pyelonephritis is characterized by an unclear clinical picture - general weakness, headache, and fatigue quickly. High temperatures are rare. Impaired urination, pain in the lumbar region and swelling are usually absent, but Pasternatsky's symptom sometimes appears. There is a small amount of protein in the urine, and the number of leukocytes and bacteria changes. In addition, the latent form is usually accompanied by impaired renal function, primarily their ability to concentrate, which manifests itself in increased urine formation and hyposthenuria - the excretion of urine with low specific gravity.

Patients with a latent form of chronic pyelonephritis can remain able to work for a long time. Permission to work is limited only to high arterial hypertension and is completely excluded in case of its malignant course, as well as in cases of impaired nitrogen excretory function of the kidneys.

In the recurrent form of chronic pyelonephritis, alternating periods of exacerbations and remissions are characteristic. Patients experience constant discomfort in the lumbar region, the process of urination is disrupted, and after a chill, the temperature may suddenly rise, and signs of acute pyelonephritis appear.

As the recurrent form intensifies, the symptoms of certain diseases begin to predominate.

In some cases, hypertensive syndrome may develop with its characteristic symptoms - headaches, dizziness, disorders, pain in the heart, etc.

In other cases, anemic syndrome becomes predominant - general weakness, fatigue, shortness of breath. Subsequently, chronic renal failure develops.

With an exacerbation of the disease, pronounced changes in the composition of urine occur - proteinuria, leukocyturia, cylindruria, bacteriuria and hematuria are possible. As a rule, the patient's blood ESR increases and the number of neutrophils increases (neutrophilic leukocytosis).

Hypertensive form of chronic pyelonephritis characterized primarily by the presence of hypertension. Patients suffer from dizziness, headaches, pain in the heart, and shortness of breath. They develop insomnia and hypertensive crises. Often hypertension is malignant. There are usually no disturbances in urination.

Anemic form of chronic pyelonephritis is characterized by the fact that among the signs of the disease, symptoms of anemia predominate - a decrease in the number of full-fledged red blood cells. This form of the disease in patients with chronic pyelonephritis is more common, more pronounced than in other kidney diseases, and is usually hypochromic in nature. Disturbances in urination are mild.

To the azotemic form of chronic pyelonephritis These include those cases when the disease manifests itself in the form of chronic renal failure. They should be qualified as a continuation of an already existing, but not timely identified latent course of the disease. It is the azotemic form that is characteristic of chronic renal failure.

Hematuric form of chronic pyelonephritis known for repeated attacks of macrohematuria and persistent microhematuria, which is associated with venous hypertension, which contributes to the disruption of the integrity of the vessels of the fornical zone of the kidney and the development of fornical bleeding.

Chronic pyelonephritis usually develops over 10–15 years or more and ends with shrinkage of the kidneys. Wrinkling occurs unevenly with the formation of rough scars on the surface. If only one of the kidneys shrinks, then, as a rule, compensatory hypertrophy and hyperfunction of the second kidney is observed. That is, within a few weeks the mass of the remaining kidney increases, and it takes over the functions of the diseased kidney. At the final stage of chronic pyelonephritis, when both organs are affected, chronic renal failure develops.

DIAGNOSIS OF CHRONIC PYELONEPHRITIS

Chronic pyelonephritis is recognized based on:

Anamnesis data (medical history),

Available symptoms

Results of leukocyturia - examination of urinary sediment using the Kakovsky-Addis method,

Quantitative detection of active leukocytes in urine, called Stenheimer-Malbin cells,

Bacteriological urine analysis,

Kidney biopsies.

It is often not possible to identify chronic pyelonephritis and accurately determine the form of its course in a timely manner, especially in a clinic setting due to the variety of clinical manifestations of the disease and the relatively frequent latent course.

Also, if chronic pyelonephritis is suspected, a general blood test is performed to determine residual nitrogen, urea and creatinine in it, the electrolyte composition of blood and urine is determined, and the functional state of the kidneys is examined.

Using the X-ray method, changes in the size of the kidneys, deformation of their pelvis and calyces, and disturbances in the tone of the upper urinary tract are determined, and radioisotope renography allows one to obtain a graphic image and evaluate the functional state of each organ separately.

An additional research method for diagnosing chronic pyelonephritis is intravenous and retrograde pyelography and scenography, echographic examination of the kidneys, and chromocystoscopy.

It is necessary to distinguish chronic pyelonephritis from chronic glomerulonephritis, amyloidosis, hypertension, diabetic glomerulosclerosis.

Unlike chronic pyelonephritis, chronic glomerulonephritis is characterized by an increased concentration of red blood cells in the urinary sediment, the absence of active leukocytes and the presence of microbes in the urine. Amyloidosis can be recognized by the presence of foci of chronic infection, paucity of urinary sediment (there are only single leukocytes, red blood cells and casts, no sugar at all), as well as by the absence of bacteriuria and radiological signs of pyelonephritis.

Hypertonic disease It is more often observed in older people, occurs with hypertensive crises and more pronounced sclerotic changes in the coronary, cerebral vessels and aorta. In patients with hypertension, there is no leukocyturia, bacteriuria, or pronounced decrease in the relative density of urine characteristic of chronic pyelonephritis, and X-ray and radioindication studies do not reveal changes inherent in chronic pyelonephritis. With diabetic glomerulosclerosis, the patient has signs and other symptoms of diabetic angiopathy - generalized damage to blood vessels.

TREATMENT OF CHRONIC PYELONEPHRITIS

Treatment of chronic pyelonephritis is at least four months. If the disease proceeds without complications, therapy can be reduced on the recommendation of a doctor.

Every month the patient undergoes a urine test and an antibiogram. If the white blood cell count is still higher than normal, the drug should be replaced. Sometimes it happens that a month after the start of treatment, the tests are normal. But this does not mean that the disease has passed and the kidneys are out of danger. Under no circumstances should you give up treatment.

Antibacterial therapy is currently the main method of treating chronic pyelonephritis. Antibiotics are started only after the causative agent of the infection has been identified and its sensitivity to drugs has been determined. Antibiotics that suppress gram-negative flora are usually indicated. The doctor should prescribe only those drugs that do not have a toxic effect on the kidneys. Treatment is carried out with regular laboratory monitoring of the sensitivity of microflora to the antibiotic.

Modern fluoroquinolone antibiotics have a good therapeutic effect with a low probability of relapses and adverse reactions: ciprofloxacin, norfloxacin, levofloxacinpefloxacin; cephalosnorins: cephalexin, cefuroxime, cefenim, semisynthetic penicillins with beta-lacgamase inhibitors augmentin, unasin.

Taking non-steroidal anti-inflammatory drugs that prevent the formation of blood clots in blood vessels is also suggested in the complex treatment of chronic pyelonephritis. This could be aspirin, movalis, voltaren, ibuprofen and others. To improve microcirculation in the kidneys, patients take chimes, tren-tal or venoruton, and to activate renal circulation - urolisan, cystenal, olimetsn, uroflux.

The doctor may prescribe immunocorrective drugs for severe disease and complications, especially in older people. If a chronic urinary tract infection is detected, peptide bioregulators are prescribed.

To prevent taking antibiotics, especially powerful ones (the so-called fourth line), from leading to intestinal dysbiosis, you must follow a fermented milk diet throughout the entire course of treatment. But if dysbiosis does appear, then to restore the intestinal microflora, about a week before the end of the main therapy, it is necessary to start taking bifidumbacterin. In difficult cases, the doctor may prescribe antifungal drugs.

Prevention of the development of chronic pyelonephritis and its complications is possible only with constant monitoring of the patient by a urologist. Control tests and studies should be done at least three times a year. During this period, the patient should not have heavy physical exertion, hypothermia, or high humidity at work; such people should not work the night shift. Patients are removed from the register if they do not show signs of exacerbation of chronic pyelonephritis within two years.

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

Treatment of chronic pyelonephritis

Chronic pyelonephritis- a chronic nonspecific infectious-inflammatory process with predominant and initial damage to the interstitial tissue, pyelocaliceal system and renal tubules with subsequent 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, and the degree of chronic renal failure.

Indications for hospitalization of the patient are:

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

In any phase of the disease, patients should not be cooled, and significant physical activity should also be avoided.
With a latent course of chronic pyelonephritis with normal blood pressure or mild arterial hypertension, as well as with preserved renal function, regimen restrictions are not required.
During exacerbations of the disease, the regime is limited, and patients with a high degree of activity and fever are prescribed bed rest. Visits to the dining room and toilet are allowed. In patients with high arterial hypertension and renal failure, it is advisable to limit physical activity.
As the exacerbation is eliminated, the symptoms of intoxication disappear, blood pressure normalizes, and the symptoms of chronic renal failure decrease or disappear, the patient’s regimen expands.
The entire period of treatment for exacerbation of chronic pyelonephritis until the regime is fully expanded takes about 4-6 weeks (S.I. Ryabov, 1982).

In case of chronic pyelonephritis, it is advisable to prescribe predominantly acidifying foods (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 unfavorable conditions for microorganisms.

3. Etiological treatment

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

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

Anti-infective therapy for chronic pyelonephritis is the most important measure for both the secondary and primary variants of the disease (not associated with impaired urine outflow 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 chronic renal failure, the influence of urine reaction on the activity of drugs.

Chronic pyelonephritis is caused by a wide variety of flora. The most common pathogen is Escherichia coli, in addition, the disease can be caused by enterococcus, Proteus vulgaris, staphylococcus, streptococcus, Pseudomonas aeruginosa, mycoplasma, and less commonly by fungi and 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 cell wall. The L-form is an adaptive form of microorganisms in response to chemotherapeutic agents. Non-enveloped 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 (while bacteria are not detected by conventional methods).

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

The main causative agents of pyelonephritis are sensitive to the following uroantiseptics.
Escherichia coli: highly effective are chloramphenicol, ampicillin, cephalosporins, carbenicillin, gentamicin, tetracyclines, nalidixic acid, nitrofuran compounds, sulfonamides, phosphacin, nolicin, palin.
Enterobacter: highly effective chloramphenicol, gentamicin, palin; Tetracyclines, cephalosporins, nitrofurans, and nalidixic acid are moderately effective.
Proteus: ampicillin, gentamicin, carbenicillin, nolicin, palin are highly effective; Levomycetin, cephalosporins, nalidixic acid, nitrofurans, sulfonamides are moderately effective.
Pseudomonas aeruginosa: gentamicin and carbenicillin are highly effective.
Enterococcus: ampicillin is highly effective; Carbenicillin, gentamicin, tetracyclines, and nitrofurans are moderately effective.
Staphylococcus aureus (does not form penicillinase): penicillin, ampicillin, cephalosporins, gentamicin are highly effective; Carbenicillin, nitrofurans, and sulfonamides are moderately effective.
Staphylococcus aureus (forming penicillinase): oxacillin, methicillin, cephalosporins, gentamicin are highly effective; Tetracyclines and nitrofurans are moderately effective.
Streptococcus: penicillin, carbenicillin, cephalosporins are highly effective; Ampicillin, tetracyclines, gentamicin, sulfonamides, nitrofurans are moderately effective.
Mycoplasma infection: tetracyclines and erythromycin are highly effective.

Active treatment with uroantiseptics must begin from the first days of exacerbation and continue until all signs of the inflammatory process are eliminated. After this, an anti-relapse course of treatment must be prescribed.

Basic rules for prescribing antibacterial therapy:
1. Correspondence of the antibacterial agent and the sensitivity of the urine microflora to it.
2. The dosage of the drug should be made taking into account the state of kidney function and the degree of chronic renal failure.
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, the drug should be changed within 2-3 days from the start of treatment.
5. In case of a high degree of activity of the inflammatory process, severe intoxication, severe course of the disease, or 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 the antibacterial agent.

The following antibacterial agents are used in the treatment of chronic pyelonephritis: antibiotics ( table 1), sulfonamide 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 units 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	Orally 0.5 g every 8 hours
Augmentin (amoxicillin + clavulanate)	Intramuscularly 1.2 g 4 times a day
Unazine (ampicillin + sulbactam)	Orally 0.375-0.75 g 2 times a day, intramuscularly 1.5-3 g 3-4 times a day
Ampiox (ampicillin + oxacillin)	Orally 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 intravenously drip
Cephalosporins
Cefazolin (kefzol)	Intramuscularly, intravenously 1-2 g every 8-12 hours
Cephalothin	Intramuscularly, intravenously 0.5-2 g every 4-6 hours
Cephalexin
Cefuroxime (ketocef)	Intramuscularly, intravenously 0.75-1.5 g 3 times a day
Cefuroxime-axetil	Orally 0.25-0.5 g 2 times a day
Cefaclor (ceclor)	Orally 0.25-0.5 g 3 times a day
Cefotaxime (claforan)	Intramuscularly, intravenously 1-2 g 3 times a day
Ceftizoxime (epoceline)	Intramuscularly, intravenously 1-4 g 2-3 times a day
Ceftazidime (Fortum)	Intramuscularly, intravenously 1-2 g 2-3 times a day
Cephobid (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 of 0.5-1 g per 100 ml of 5% glucose solution or intramuscularly of 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	Intramuscular, intravenous drip in 5% glucose solution
Amikacin	Intramuscularly, intravenously 15 mg/kg per day in 2 doses
Tetracyclines
Metacycline (Rondomycin)	Orally 0.3 g 2 times a day 1-1.5 hours before meals
Doxycycline (Vibramycin)	Orally, intravenously (drip) 0.1 g 2 times a day
Lincosamines
Lincomycin (lincocin)	Inside, intravenously, intramuscularly; orally 0.5 g 4 times a day; parenterally 0.6 g 2 times a day
Clindamycin (Dalacin)	Orally 0.15-0.45 g every 6 hours; intravenously, intramuscularly 0.6 g every 6-8 hours
Levomycetin group
Chloramphenicol (chloramphenicol)	Orally 0.5 g 4 times a day
Levomycetin succinate (chlorocide C)	Intramuscularly, intravenously 0.5-1 g 3 times a day
Fosfomycin (phosphocin)	Orally 0.5 g every 6 hours; intravenous stream, drip 2-4 g every 6-8 hours

3.1.1. Penicillin group drugs
In case of 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 penicillin group of drugs. These drugs actively affect 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: unasin (ampicillin + sulbactam) or augmentin (amoxicillin + clavulanate). Carbenicillin and azlocillin have pronounced antipseudomonal activity.

3.1.2. Drugs 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. Of the cephalosporins, only ceftazidime (Fortum) and cefoperazone (cephobid) have an active effect on Pseudomonas aeruginosa.

3.1.3. Carbapenem drugs
Carbapenems have a wide spectrum of action (gram-positive and gram-negative flora, including Pseudomonas aeruginosa and staphylococci that produce penicillinase - beta-lactamase).
When treating pyelonephritis from drugs in 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 multi-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 are highly resistant to the action of penicillinases (beta-lactamases). Drugs in this group include aztreonam (azactam).

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

3.1.6. Lincosamine preparations
Lincosamines (lincomycin, clindamycin) have a bacteriostatic effect and have a fairly narrow spectrum of activity (gram-positive cocci - streptococci, staphylococci, including those that produce penicillinase; non-spore-forming anaerobes). Lincosamines are not active against enterococci and gram-negative flora. Resistance of microflora, especially staphylococci, quickly develops to lincosamines. In severe cases of chronic pyelonephritis, lincosamines should be combined with aminoglycosides (gentamicin) or other antibiotics acting 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 for pyelonephritis and is even considered a reserve drug for this disease.

3.1.9. Accounting for urine reaction
When prescribing antibiotics for pyelonephritis, the urine reaction should be taken into account.
With an acidic urine reaction, the effect of the following antibiotics is enhanced:
- penicillin and its semisynthetic preparations;
- tetracyclines;
- novobiocin.
When urine is alkaline, the effect 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 are used less frequently than antibiotics in the treatment of patients with chronic pyelonephritis. They have bacteriostatic properties and act on gram-positive and gram-negative cocci, gram-negative “bacillus” (Escherichia coli), and chlamydia. However, enterococci, Pseudomonas aeruginosa, and anaerobes are not sensitive to sulfonamides. The effect of sulfonamides increases with alkaline urine.

Urosulfan - 1 g is prescribed 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, mycoplasma). The drugs do not act on Pseudomonas aeruginosa and anaerobes.
Bactrim (Biseptol) is a combination of 5 parts sulfamethoxazole and 1 part trimethoprim. Prescribed orally in tablets of 0.48 g, 5-6 mg/kg per day (in 2 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 prescribed 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 urine and almost do not precipitate in the form of crystals in the urinary tract, but it is still advisable to wash down each dose with soda water. It is also necessary to monitor the number of leukocytes in the blood during treatment, as leukopenia may develop.

3.3. Quinolones

Quinolones are based on 4-quinolone and are classified into two generations:
I generation:
- nalidixic acid (nevigramone);
- oxolinic acid (gramurin);
- pipemidic acid (palin).
II generation (fluoroquinolones):
- ciprofloxacin (ciprobay);
- ofloxacin (Tarivid);
- pefloxacin (abactal);
- norfloxacin (nolitsin);
- lomefloxacin (maxaquin);
- enoxacin (Penetrex).

3.3.1. I generation quinolones
Nalidixic acid (nevigramon, negram) - the drug is effective against urinary tract infections caused by gram-negative bacteria, except Pseudomonas aeruginosa. Ineffective against gram-positive bacteria (staphylococcus, streptococcus) and anaerobes. It has a bacteriostatic and bactericidal effect. When taking the drug orally, a high concentration of it is created in the urine.
When urine becomes alkaline, the antimicrobial effect of nalidixic acid increases.
Available in capsules and tablets of 0.5 g. Prescribed orally, 1-2 tablets 4 times a day for at least 7 days. For long-term treatment, use 0.5 g 4 times a day.
Possible side effects of the drug: nausea, vomiting, headache, dizziness, allergic reactions (dermatitis, fever, eosinophilia), increased skin sensitivity to sunlight (photodermatoses).
Contraindications to the use of nevigramon: impaired liver function, renal failure.
Nalidixic acid should not be prescribed 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 (Escherichia coli, Proteus), Staphylococcus aureus.
Available in tablets of 0.25 g. Prescribed 2 tablets 3 times a day after meals for at least 7-10 days (up to 2-4 weeks).
The side effects are the same as when treated with Nevigramon.

Pipemidic acid (palin) is effective against gram-negative flora, as well as pseudomonas, staphylococci.
Available in capsules of 0.2 g and tablets of 0.4 g. Prescribed 0.4 g 2 times a day for 10 days or more.
The drug is well tolerated, sometimes there is nausea and allergic skin reactions.

3.3.2. II generation quinolones (fluoroquinolones)
Fluoroquinolones are a new class of synthetic broad-spectrum antibacterial agents. Fluoroquinolones have a wide spectrum of action, they are active against gram-negative flora (Escherichia 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, and 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 (Ciprobay) is the “gold standard” among fluoroquinolones, as its antimicrobial action is superior to many antibiotics.
Available in tablets of 0.25 and 0.5 g and in bottles 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; in case of very severe exacerbation of pyelonephritis, the drug is first administered intravenously in a drip of 0.2 g 2 times a day, and then oral administration is continued.

Ofloxacin (Tarivid) - 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 a dose of 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) - available in tablets of 0.4 g and ampoules of 5 ml containing 400 mg of abactal. It is prescribed orally 0.2 g 2 times a day with meals; in severe cases, 400 mg is administered intravenously in 250 ml of a 5% glucose solution (abactal cannot be dissolved in saline solutions) in the morning and evening, and then switched to oral administration.

Norfloxacin (nolicin) - available in tablets of 0.4 g, prescribed 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 (Maxaquin) - available in tablets of 0.4 g, prescribed orally at 400 mg once a day for 7-10 days, in severe cases it can be used for a longer period (up to 2-3 months).

Enoxacin (Penetrex) - available in tablets of 0.2 and 0.4 g, 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 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; for chronic urinary tract infections, longer use is possible (3-4 weeks).

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

3.4. Nitrofuran compounds

Nitrofuran compounds have a wide spectrum of activity (gram-positive cocci - streptococci, staphylococci; gram-negative bacilli - Escherichia coli, Proteus, Klebsiella, Enterobacter). Anaerobes and 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 with renal failure and long-term treatment (more than 1.5 months).
Contraindications to the use of nitrofuran compounds: severe liver pathology, renal failure, diseases of the nervous system.
The following nitrofuran compounds are most often used in the treatment of chronic pyelonephritis.

Furadonin - available in tablets of 0.1 g; is well absorbed from the gastrointestinal tract, creates low concentrations in the blood, high concentrations in the urine. Prescribed orally 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 not advisable for acute pyelonephritis, since it does not create a high concentration in the kidney tissue.

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

Nitrofuran compounds combine well with aminoglycoside antibiotics and cephalosporins, but do not combine with penicillins and chloramphenicol.

3.5. Quinolines (8-hydroxyquinoline derivatives)

Nitroxoline (5-NOK) - 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 quickly absorbed from the gastrointestinal tract, excreted unchanged by the kidneys and creates a high concentration in the urine.
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. If necessary, it can be used long-term 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-NOK, the urine becomes saffron yellow.

When treating patients with chronic pyelonephritis, the nephrotoxicity of drugs should be taken into account and preference should be given to the least nephrotoxic ones - penicillin and semisynthetic penicillins, carbenicillin, cephalosporins, chloramphenicol, erythromycin. The group of aminoglycosides is the most nephrotoxic.

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

With the development of chronic renal failure, the doses of uroantiseptics are reduced and the intervals are increased (see "Treatment of chronic renal failure"). Aminoglycosides are not prescribed for chronic renal failure; nitrofuran compounds and nalidixic acid can be prescribed for chronic renal failure 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% when the urea content in the blood increases by more than 2.5 times compared to the norm: penicillin, ampicillin, oxacillin, methicillin; these drugs are not nephrotoxic, but in chronic renal failure they accumulate and cause side effects;
• antibacterial drugs, the use of which in chronic renal failure requires mandatory dose adjustment and administration intervals: 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 antibacterial 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. A combination of penicillin and its semisynthetic drugs is effective. Nalidixic acid preparations can be combined with antibiotics (carbenicillin, aminoglycosides, cephalosporins). 5-NOK is combined with antibiotics. Bactericidal antibiotics (penicillins and cephalosporins, penicillins and aminoglycosides) combine well and mutually enhance the effect.

After the patient reaches remission, antibacterial treatment should be continued in intermittent courses. Repeated courses of antibacterial therapy for patients with chronic pyelonephritis must be prescribed 3-5 days before the expected appearance of signs of exacerbation of the disease so that the remission phase is constantly maintained 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 revealed, since there is no bacteriuria in the latent phase of inflammation and during remission.

Methods of anti-relapse courses for chronic pyelonephritis are outlined below.

A. Ya. Pytel recommends treating chronic pyelonephritis in two stages. During the first period, treatment is carried out continuously, replacing 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 this, intermittent treatment with antibacterial drugs is carried out for 4-5 months for 15 days at intervals of 15-20 days. In case of stable long-term remission (after 3-6 months of treatment), antibacterial agents may not be prescribed. After this, anti-relapse treatment is carried out - sequential (3-4 times a year) course use of antibacterial agents, antiseptics, and medicinal plants.

4. Use of NSAIDs

In recent years, the possibility of using NSAIDs for 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 mild immunosuppressant effect, antipyretic and analgesic effect.
In addition, the use of NSAIDs is aimed at reducing reactive phenomena caused by the infectious process, preventing proliferation, and destroying fibrous barriers so that antibacterial drugs reach the inflammatory focus. However, it has been established that indomethacin, with long-term use, can cause necrosis of the renal papillae and impaired hemodynamics of the kidney (Yu. A. Pytel).
Of the NSAIDs, the most appropriate is to take 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.Improving renal blood flow

Impaired renal blood flow plays an important role in the pathogenesis of chronic pyelonephritis. It has been established that with this disease there is an uneven distribution of renal blood flow, which is expressed in hypoxia of the cortex 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 red blood cells, reduces platelet aggregation, enhances glomerular filtration, has a mild diuretic effect, increases the delivery of oxygen to the area of ​​tissue affected by ischemia, as well as the pulse blood supply to the kidney.
Trental is prescribed 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 treatment is 3-4 weeks.

Curantil - reduces platelet aggregation, improves microcirculation, 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 10% solution.
Yu. A. Pytel and Yu. M. Esilevsky suggest, in order to reduce the treatment time for exacerbation of chronic pyelonephritis, in addition to antibacterial therapy, prescribe venoruton intravenously at a dose of 10-15 mg/kg for 5 days, then orally 5 mg/kg 2 times a day day throughout the course of treatment.

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

6. Functional passive kidney exercises

The essence of functional passive kidney exercises is the periodic alternation of functional load (due to the administration of saluretic) and a state of relative rest. Saluretics, causing polyuria, contribute to the maximum mobilization of all the reserve capabilities of the kidney by including a large number of nephrons in the activity (under normal physiological conditions, only 50-85% of the glomeruli are in an active state). With functional passive exercises 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 and in the kidney tissue increases, and their effectiveness in the area of ​​inflammation increases.

Lasix is ​​usually used as a means of functional passive kidney exercises (Yu. A. Pytel, I. I. Zolotarev, 1983). Prescribed 2-3 times a week 20 mg of Lasix intravenously or 40 mg of furosemide orally with monitoring of daily diuresis, electrolytes in the blood serum and biochemical blood parameters.

Negative reactions that may occur during passive kidney exercises:

• long-term use of the method can lead to depletion of the reserve capacity of the kidneys, which is manifested by a deterioration in their function;
• uncontrolled passive kidney exercises can lead to disruption of water and electrolyte balance;
• Passive kidney exercises are contraindicated in cases of impaired urine passage from the upper urinary tract.

7. Herbal medicine

In the complex therapy of chronic pyelonephritis, drugs are used that have an anti-inflammatory, diuretic, and, in the case of hematuria, a hemostatic effect ( table 2).

Table 2. Medicinal plants used for chronic pyelonephritis

Plant name	Action
	diuretic	bactericidal	astringent	hemostatic
Althea 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. Used in the form of decoctions (30 g per 500 ml) 2 tablespoons 5-6 times a day. Bearberry exhibits its effect in an alkaline environment, so taking the decoction should be combined with ingesting alkaline mineral waters (Borjomi) and soda solutions. To alkalize urine, use apples, pears, and raspberries.

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

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

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

Collection No. 1

Collection No. 2

Collection No. 3

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

Collection No. 4

The following collection is recommended as maintenance antibiotic therapy:

Collection No. 5

It is considered appropriate for chronic pyelonephritis to prescribe combinations 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 with medicinal plants takes a long time - months and even years.
During the entire autumn season, it is advisable to eat watermelons due to their pronounced diuretic effect.

Along with taking infusions, baths with medicinal plants are useful:

Collection No. 6(for Bath)

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

In order to increase the body's reactivity and to quickly stop an exacerbation, the following are recommended:

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

In recent years, a major role of autoimmune mechanisms in the development of chronic pyelonephritis has been established. Autoimmune reactions are promoted by a deficiency of T-suppressor function of lymphocytes. Immunomodulators are used to eliminate immune disorders. They are prescribed for long-term, poorly controlled 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. 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 danger of leukopenia).

Timalin - normalizes the function of T- and B-lymphocytes, administered intramuscularly at 10-20 mg once a day for 5 days.

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

By reducing the severity of autoimmune reactions and 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 monitor the immune status.

9. Physiotherapeutic treatment

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

The following physiotherapy procedures are used.
1. Electrophoresis of furadonin 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 units, ethyl alcohol 70% - 100 g. The movement of the drug occurs from the anode to the cathode.
3. Calcium chloride electrophoresis on the kidney area.
4. USV at a dose of 0.2-0.4 W/cm 2 in pulse mode for 10-15 minutes in the absence of urolithiasis.
5. Centimeter waves (“Luch-58”) to 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, ozokerite and paraffin applications.

10. Symptomatic treatment

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

11. Spa treatment

The main sanatorium-resort factor for chronic pyelonephritis is mineral waters, which are used internally 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, and affect urine pH (shift the urine reaction to the alkaline side).

The following resorts with mineral waters are used: 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 promotes the passage of small stones. In addition, it also has an anti-inflammatory effect.

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

Taking mineral waters internally helps reduce inflammation in the kidneys and urinary tract, “washing out” mucus, microbes, small stones, and “sand” from them.

At resorts, treatment with mineral waters is combined with physiotherapeutic treatment.

Contraindications to sanatorium-resort treatment are:
- high arterial hypertension;
- severe anemia;
- CRF.

12. Planned anti-relapse treatment

The goal of planned anti-relapse treatment is to prevent the development of relapse and exacerbation of chronic pyelonephritis. There is no unified 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-NOK at night;
4th week - chloramphenicol (1 tablet at night).
In subsequent months, maintaining the specified sequence, you can replace the drugs with similar ones from the same group. If there is no 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 exacerbation, breaks in treatment lasting 1-2 weeks are possible.

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

Chronic pyelonephritis is a kidney disease that poses a threat to the general condition of the body. What is chronic pyelonephritis and how can it 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). However, doctors also identify other causes of chronic pyelonephritis:

• Hormonal imbalances and gynecological diseases in women;
• Decreased immunity;
• Promiscuous sexual intercourse;
• Stress and emotional stress;
• Hypothermia;
• Diabetes.

The disease can be caused by different types of bacteria:

• Escherichia coli;
• Enterococci;
• Proteus;
• Staphylococcus;
• Streptococci.

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

• Cholecystitis;
• Appendicitis;
• Enterocolitis;
• Tonsillitis;
• Otitis;
• Sinusitis, etc.

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

Incorrectly prescribed therapy threatens the patient with an increase in recovery time 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 infection, chronic pyelonephritis is divided into three phases:

1. Active inflammation phase;
2. Latent inflammation phase;
3. Remission phase.

Each phase has differences both in symptoms and research results. Adequate treatment contributes to the transition of the acute period to the latent period. The latent period is expressed very weakly, almost imperceptibly. The patient may be bothered by general fatigue, low-grade body temperature and headaches. There may be no symptoms specifically indicating a genitourinary disease. After several months, the disease, which had been latent, gives way to recovery (remission) or a new attack. In the acute stage, it is already possible to clearly distinguish the symptoms inherent in pyelonephritis. Urine culture during this period also indicates pathology. Bacteria and leukocytes are released into the urine (bacteriuria and leukocyturia), as well as protein up to 3 g/l (proteinuria).

Based on their occurrence, there are two forms of chronic pyelonephritis:

1. Primary – not associated with previous urological diseases. When studying the pathology of this form, doctors usually do not find factors that could contribute to the retention of bacteria in the kidney tissues.
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 location of pyelonephritis, the following forms are distinguished:

• Left-handed;
• Right-handed;
• Bilateral.

Symptoms

The 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). Doctors suspect chronic pyelonephritis even with the following signs:

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

It should be noted that symptoms in the acute phase are more pronounced and require immediate treatment. The feeling of pain becomes unbearable. A symptom of exacerbation such as high temperature 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 are not attributed either to the patient or to the doctors to a disease of a urological nature. Thus, chronic pyelonephritis can result in high blood pressure (hypertension). Kidney function and the cardiovascular system are closely related. If the condition of the kidneys worsens, a hypertensive crisis occurs. Increased blood pressure is quite common in patients with kidney disease (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 make an accurate diagnosis and treatment. In men, 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 even occur in infants and infants. In children, pyelonephritis most often has obvious symptoms. A feature of the course of pyelonephritis in children is very rapid intoxication due to a rise in temperature. At home, you can help your baby with symptomatic treatment methods:

• Bed rest;
• Anesthesia;
• Decreased body temperature.

Diagnostics

It is easiest to diagnose chronic pyelonephritis in a hospital setting. To make a diagnosis, an experienced nephrologist usually only needs to order 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 test results 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, test data are always compared with the patient’s complaints and the overall clinical picture. An ultrasound will show possible diffuse changes in the kidneys. To more accurately formulate a diagnosis, the doctor may prescribe additional tests. There are often cases when the disease is diagnosed by chance, during examination for another disease.

Treatment

Chronic pyelonephritis is treated comprehensively. Antibiotics and uroseptics are used. The doctor may also prescribe herbal remedies. The successful outcome of treatment largely depends on preliminary urine culture to determine drug sensitivity. In this way, 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 hydroxyquinoline drugs (Nitroxoline) are well tolerated by humans, but bacteria have also recently become less sensitive to them. Treatment can be prescribed either in tablet form or in injections.

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

Treatment in the remission stage comes down to preventive measures:

• Diet;
• Drinking regime;
• 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 when choosing a sanatorium for kidney treatment is the availability of mineral waters. Using the healing properties of water, harmful substances are removed from the kidneys and inflammatory processes are eliminated. The medical standard of modern resorts involves a nursing process. This is an integrated approach to treating patients, including the provision of professional medical care and patient care. Modern clinics also provide quality nursing care.

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 had previously been seen by a doctor. Ignoring medical instructions can have serious consequences for the patient. Untreated pyelonephritis is dangerous due to 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 care of your health. Do not self-medicate, get tested 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 of necessary substances occurs faster in the renal tubules. In addition, ASD-2 helps restore the body’s adaptive capabilities, normalizing Ph-balance and increasing resistance to pathogenic factors (physical, emotional overload and stress). At the remission stage, this is an excellent remedy, thanks to which the disease can completely go away.

Diet

Diet is the basis for the treatment of chronic pyelonephritis. For patients who have suffered acute pyelonephritis, the “Table 7” diet is indicated. The diet of a patient with pyelonephritis should include natural foods, steamed or boiled. It is necessary to reduce salt intake to a minimum. It is better to replace purified tap water with mineral water.

What you can eat:

• Low-fat 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 rolls.

Eating this therapeutic diet is not so difficult. It is enough to get used to the natural taste of the 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 to avoid overcooling and eliminate foci of infections in the body in a timely manner. It is very important to strengthen the immune system from the inside with vitamins, proper balanced nutrition and hardening procedures. Be sure to have blood and urine tests done once a year or more often.

During pregnancy

Chronic pyelonephritis and pregnancy are quite common. 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 removed from the body in time - inflammation occurs. Pregnancy itself with chronic pyelonephritis can proceed quite normally. However, the condition of the expectant mother leaves much to be desired. To complicate the situation, antibiotic therapy is contraindicated during pregnancy. After passing all the necessary tests and confirming the diagnosis, the attending physician prescribes the most appropriate medications with minimal risk to the child. Many mothers are concerned about the question of whether it is possible to give birth if this disease was discovered during pregnancy. Doctors say that timely detection of pathology and control over it allows women to give birth independently in 95% of cases.

Do they take into the army with chronic pyelonephritis?

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