Download Clinical laboratory indicators

Glomerulonefritis at
children
GLOMERULONEFRIT (GN).
Treats immunopathological diseases, it is
characterized by primary defeat of kidney balls, it
is clinically shown by a proteinuria, a gematuriya
and arterial hypertension. It is observed at 0,7 —
14 of 1000 children. Distinguish the primary GN
developing in 1 — 3 weeks after influence of
infectious and noninfectious factors, and the
secondary GN arising against system diseases
(system red a wolf cub, etc.)
• Etiology. GN is a polyethiologic disease,
develops after a streptococcal infection more
often (r-haemo lytic, the group A, types 12, 4,
25, 49), is more rare after virus infections (the
NV-virus, etc.), after preventive inoculations, a
sting of a snake or bees, after overcooling and
other reasons.
Risk factors
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Exogenous factors:
bacteria (a certain nefritogennost possess
B-hemo lytic streptococcus of group (types of 4,12,25 m 9)
Viruses
Parasites
Fungi
drugs
Endogenous anti-genes:
nuclear anti-genes
immunoglobulin at rheumatoid arthritis
Pathogenesis
• In development of GN there are two main mechanisms:
• Initially - the autoimmune mechanism of development of GN
assumes at 5% of people and is shown in the expressed
proliferative and necrosis changes of balls with linear endothelial
deposits of immunoglobulin's and a complement, and also in
early development of a sclerosis of renal fabric.
• At the immunocomplex mechanism of development GN
meeting in 95% of cases an illness begins as follows: impact on
an anti-gene organism with the subsequent formation of
antibodies and the soluble Central Election Commissions an
anti-gene - an antibody
Clinical pictures
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During OGN it is allocated the periods:
initial manifestations (to 4х weeks)
return development of process (2-4 months)
clinical-laboratory remission.
In the period of initial disease manifestation with a various
frequency it is observed 4 main clinical syndromes:
a nephritic syndrome - 23,3%
a nephrotic syndrome with a gematuriya and a hypertension of31,2%
a nephrotic syndrome – 6,2%
the isolated uric syndrome – 34,3%.
• At a nephritic syndrome – the typical or classical beginning of sharp GN on
2-3 week after transferred quinsy and infectious process, appear flow, pallor
of skin and mucous membranes is more often on a face,
• Nephrotic syndrome - at children it is peculiar widespread hypostases and
absence of arterial hypertension. Hypostases are most expressed in the
morning – on a face, under eyes, at an internal anklebone, on a scrotum
• the isolated uric syndrome - symptoms of the general intoxication are
expressed poorly, and hypostases aren't observed, a makrogematuriya, a
proteinuria, increase of relative density of urine.
• nephrotic a syndrome with a gematuriya and a hypertension - in an initial
stage of a disease take place expressed flow, a makrogemoturiya, arterial
hypertension.
• At favorable currents, being observed the majority of children,
since the end of 3-4 weeks from emergence of the first
symptoms of a disease the period of the return development of
process begins.
• First of all begins will gradually decrease, and to disappear
arterial hypertension and hypostases.
• Elimination of an uric syndrome and complete recovery of
kidney functions happens in 3-6 months. Then there comes the
period of clinical-laboratory remission.
• Exception late diagnosed cases of AG, stratification make
infections existence of the center of an infection.
• In these conditions of AGN accepts a long, wavy current
duration till 1 year and more, coming to an end further with an
absolute recovery or transition to chronic process.
• Atypical forms sharp treat:
• being shown separate symptoms – only AI
hypertensia or only hypostases
• warmly – vascular insufficiency
• kidney insufficiency
• Angiospastic encephalopathy
Subsharp glomerulonephritis
• The heaviest form of the acquired inflammatory and immune
defeat of kidneys
• Meets at children rather seldom
• Development of a disease is preceded by ARD, quinsy, scarlet
fever
• The disease is shown at the beginning as AG, differs the rough
beginning, and in consequences – a progressing malignant
current
• Only in rare instances it develops hardly noticeably, for a year
• Difficult gives in to treatment
• has the bad forecast.
Clinical pictures
• PG differs malignant and steadily – a progressing current
• The average duration of a disease according to different authors
fluctuates from several months to 2 years
• In the Initial stage of PG the same signs are observed, as at AG
• Symptoms of a disease develop more roughly, reaching big
expressiveness for 4-6 day from an onset of the illness
• The general condition is sharply broken, children become
sluggish and, and dynamic, complain of a constant headache
• it is noted as well fast development of a nephrotic syndrome
with a liquid congestion in serous cavities
• The liver and spleen considerably increases in sizes
Clinical laboratory indicators
• Increase of relative density of urine which is soon replaced by a
gipoizostenuriya earlier oliguriya development
• Accruing proteinuria with protein loss with urine to 15-25 g/day
• The resistant gemoturiya, deposit of urine contains hyaline,
granular, epitritsitarny cylinders in a large number
• Change of biochemical indicators characterizes by an azotemiy
giperkreatininemiya, a hypercholesterolemia, reduction blood
protein content, generally at the expense of albumin fraction
• accruing decrease in a glomerular filtration, kanal reabsobtion
and secretion.
Chronic glomerulonephritis
• HG – the generalizing name group of diseases which
unites various on an etiology, and clinic-morphological
essence of a glomerulopatiya of the inflammatory
character, showing tendency to progressing and
development nephrosclerosis.
• Preservation of these or those symptoms of an illness
indicates more than 1 year HG development.
• Frequency of transition of OG in HG fluctuates from
7.8 to 15% and occurs, usually in 8-12 years.
HG clinic
• At HG at children allocate the nephrotic, hematuric and mixed forms
• The specified HG forms usually are formed on the 2nd year after transferred
AG
• In development and progressing of pathological process in kidneys transition
of one HG form to another is possible.
• Development of the HG nephrotic form is promoted by frequent
streptococcal and virus infections, allergic diseases, hereditary predisposition
• The disease develops gradually, the child becomes sluggish, weak, appetite
decreases
• Peripheral hypostases soft skin over them pale dry, thinned
• АP at big with nephrotic the HG form the long time remains normal
• At the majority of children the liver and a spleen increases.
Clinical laboratory indicators
• The daily allowance diuresis lowered: the proteinuria (10 g/days) is expressed
• In an urine deposit single erythrocytes and leukocytes, in a large number
hyaline and granular cylinders, cages of a kidney epithelium
• The relative density of urine is increased in the beginning, then decreases
• The content of residual nitrogen, urea, creatinine in blood is in norm limits,
substantial increase of level of cholesterol is characteristic
• The gipoproteinemiya (to 50-40 g/l) and a disproteinemiya at the expense of
increase in concentration of globulin and reduction of the content of
albumin in blood is noted expressions
• Deep frustration of a water and electrolytic exchange is found in the majority
of children.
Nephrotic form
• It is characterized by a wavy current. With each new aggravation of process at
patients all are more accurately shown symptoms of kidney insufficiency
ekstrarenaly symptomatology.
• At the HG hematuric form into the forefront the expressed and persistent
hematuriya acts
• Sometimes short-term emergence of hypostases is found in patients in eyes
and increase
• Leukocytes hyaline and granular cylinders, cages of a kidney epithelium come
to light
• The content of residual nitrogen, creatinine in blood and glomerular
filtrations aren't changed for a long time
• At children with the mixed HG form pallor of skin and mucous membranes,
of all body come to light
• А/P in the beginning diseases raises,and then it is stabilized on the high
Uric syndrome at HG
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it is shown by not selective proteinuria (2-3 g/days)
eritrocyturiya (100mln/days)
leykocyturiya (10mln/days)
in an uric deposit it is found hyaline
leykocytary, granular cylinders
cages of a kidney epithelium
symptoms of acidosis
the hypo - or a giperkaliyemiya
kanal violations
moderate decrease in a glomerular filtration.
Differential diagnosis
• Toxic defeat of kidneys at acute infectious diseases (ARD, bronchitis, a
bronchopneumonia)
• AG the isolated uric syndrome, DVS phenomena
• AG with a long current usually should be differentiated with HG in the
aggravation period
• In some cases it is necessary to differentiate with hereditary nephrite,
combined with hearing fall (Alport's syndrome) – is more rare than sight.
• Sometimes to have to differentiate the OG long forms with tuberculosis of
kidneys
• Chronic pyelonephritis unlike HG happens unilateral, often develops as a
result of an infection to urine of removing ways
• In certain cases mixed HG form should be differentiated with a family
nephrotic syndrome.
Medical actions
• Treatment is carried out by a landmark way:
• to policlinic
• specialized sanatorium at rational use of the whole
complex of the therapeutic actions including a certain
mode of physical activities and a food purpose of
symptomatic antibacterial, pathogenetic and allstrengthening of therapies in an organism
• In an initial stage of AG and HG the strict
confinement to bed (2-3 weeks) is recommended
Dietotherapy
• The products causing the phenomena of an allergy are
excluded from a diet
• Sodium chloride defiant AG and formation of
hypostases for the prevention at the patients receiving
diuretic and corticosteroid preparations is excluded.
• In an initial stage of AG or an aggravation of HG it is
used diets with restriction of chloride of sodium and
animal protein that improves function of the
glomerular device of kidneys
Symptomatic therapy
• From are applied a hydrochlorothiazide – the Dose –
2,5¼ú/kg the highly active diuretic means which action
is caused by reduction of a reabsorption of ions of
sodium and chlorine in proximal, and in distally
departments of tubules nephron.
• Lazix the diuretic effect of a preparation is connected
with oppression of a rearsobtion of ions of sodium
and chlorine proximal and distal departments of
tubules and in the field of a loop to Genl
• Etakrin acid – suppresses activity of enzyme systems
• From osmotic diuretic drugs at a nephrotic syndrome
of AG it is used mannitol.
Antibacterial therapy
• Benzilpenitsillin - to children about a year of
100 000 PIECES/kg, is more senior than year
of 50 000 PIECES/kg in 4-6 receptions
• Metetsilin
• macroleads
Pathogenetic therapy
• Dose of a preparation everyone start reducing Prednisolonum
on 1-1,5 mg/kg of the 5-10dny
• Heparin possesses antigialuronidozy and hyposensibilizing
property facilitates penetration of antibiotics into the
inflammation center. 100-150 Pieces/kg/days
• Kurantil - disaggregation of erythrocytes
• For activation of exchange processes at AG and HG application
of ATF of-1% on 1мл is recommended in/m
• Retinolum % acetate-3,44 on 3-4 to group B vitamins
• In the presence of the expressed anemia repeated
hemotransfusions are shown to patients,
Physiotherapeutic procedures
• induktotermiya
• ultrasound
• existence of functional narrowing, especially
kidney forms the basis for which application.
• At all stages of an illness, especially during the
return development of inflammatory process,
the great value has to be given to sanitation of
the centers of an infection.
Medical examination
• It is recommended to allocate 3 main groups of the dispensary accounting of
sick AG
• I - children who have been written out from a hospital in conditions of full
clinical-laboratory remission of OG belong. Survey of these children and
research of partcial functions of kidneys have to be conducted 1 time in 3
months of research of urine – monthly, a blood test – 1 time in 3мес.
• II – unites children with a complete elimination of the general clinical
manifestations
• III –belong patients with a wavy current AG which have been written out
from a hospital in conditions of incomplete clinical-laboratory remission.
Survey of such children and a blood test – each 3-4 weeks
• Dispensary supervision over children of OG is conducted 5 yeas after an
extract from a hospital.