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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 • • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • • 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.