Types of diseases
Etiologic aspects
• Obstruction of urinary tract foreign bodies, stones.
• Obstruction or sklerotizirajućim inflammatory process (tuberculosis pyelon, ureter, bladder, prostate, nespicifičan stenosing ureteritis; retroperitoneal liposkleroza and periureteritis, sclerosis of the bladder after irradiation; prostatitis with sclerosis, inflammatory stricture of the urethra - prostate for congenital disorders of development or after traumatic rupture) .
• Congenital disorders of development (expansion pyelon - ureter, cystic prošireneje final part of the ureter, bladder neck disease; retrokavalni position of the ureter, ureteral compression due to abnormal artery crossing).
• tumors (prostate adenoma; papillomatosis ureter, bladder, bladder cancer, prostate cancer, a cancer retroperitoneal adenopathy; invasion of neoplastic tissue pelvic cavity or retroperitoneal tissue compression or involvement of one or both ureters).
• Neurological disorders (paralysis of the bladder - spinal injuries, paraplegia).
The clinical aspect
• The latent form without symptoms (obstructive nephropathy without renal insufficiency).
• Acute anuria.
• Hronička progressive renal failure.
Topographic aspect
• unilateral obstruction (unilateral hydronephrosis).
• Obstruction of bilateral (processes in the retroperitoneal space, pelvic cavity with involvement of both ureters; processes localized low - bladder, prostate, urethra).
Anatomical aspects of
Mechanical obstacles (or functional) to create a unilateral hydronephrosis and ureter.
Depending on the degree of obstruction of channels and cavities pyelon calix (cup) expands at the expense of the renal parenchyma.
In extreme cases the tissue parenchyma is reduced to a thin cocoon, which is no longer distinct cortical and medullary layer, and Bertini-jeve columns and pyramids are flattened or obliterated.
In other cases diffuse fibrosis treatment parenchyma destroyed and replaced by the nephron.
Acute hydronephrosis: hiperpresija in the pelvis, increasing the volume of the kidney, renal tissue tension due to distension pyelon; perirenalnog tissue edema, venous stasis.
Depending on the nature of the obstacles, if it's removed restitution occurs without adverse effects. If it lasted longer complete or partial obstruction of the outflow of urine, hydronephrosis developed with secondary changes in the kidneys.
The functional aspect
There are various possibilities.
• Excretory function of both kidneys can be preserved.
• Global 'function can be preserved through nekompletnoj obstruction or complete obstruction, but only one kidney, while the other is able to assume the function of both.
• Acute renal failure due to complete obstruction of the urinary tract of both kidneys, or only one, and the other insufficient for any reason.
• intermittent insufficiency when the obstruction is not constant
• Renal failure with different degrees of preserved function in the excretion of urine.
Diagnosis
Anamnesis
In children, failure of urine, nocturnal enuresis, žeđanje at night, increased diuresis, back pain after urination - awaken the suspicion of congenital anomalies of development.
What type of pain occur in calculi, acute hydronephrosis.
Complaining of difficulty with urination, weak flow, interrupting the stream during urination, inability to empty the bladder.
Frequent urination, pain while urinating, involuntary release of urine - a disease of the bladder neck.
Spontaneous bleeding, unpredictable - and cease to occur without a visible, understandable reasons for kidney cancer, or bladder.
Spine injury, a disease of the spine, which led to paralysis of the bladder urine.
Conspicuous changes in diuresis: a sudden interruption of urination, urination break followed in establishing a strong diuresis polyuric crisis: polyuria.
The clinical picture
Low obstruction with complete cessation of urination:
Urinary bladder very enlarged, tense, while percussion gives muklost flat surface, the upper edge convex, hard elastic consistency, tense. Painful on palpation.
Because of anuria, urine delays in the pelvis, the kidney is enlarged, there is lumbar pain. Sometimes colic type pain, often only the weight of the loin foreface. Usually anuria mechanical origin occurs in patients with one kidney (the other hypoplastic or missing) and each acute anura, in patients with only one kidney, should be considered mechanical, until proven otherwise.
Unilateral hydronephrosis:
Vague lumbar pain. Arterial hypertension is rare. Hydronephrosis is asymptomatic until the occurrence of complications, fertilizing, calculosis, hemorrhage.
easily clinically latent, hydronephrosis due hiperrepresije compounded progressively destroying the renal parenchyma, which is being masked because of compensatory hypertrophy and functional compensation of the second kidney.
Obstruction is incomplete and diuresis held:
This situation is more common than complete obstruction. Persistent high pressure in the pelvis, although moderately elevated, causes the gradual destruction of the corresponding kidney. Pain in the lumbar foreface or severity of pelvic cavity may exist, but not always, sometimes there are problems in urination. It is seldom that there is oliguria. More often, polyuria with izostenurijom. Polyuria is sometimes as great as for diabetes insipidus.
No edema, unless associated with congestive heart failure.
If the prostate is the cause obstructions, bladder is very enlarged, stretched, with residual urine after voiding.
Means after removing mechanical obstacles:
When the obstacle was unilateral, not to be any signs of change in function, because it is effectively secured the remaining kidney excretion.
If there was polyuria hipotonična remove obstacles that do not change anything. polyuria persisted, but it can establish a function of concentration and the disappearance of the polyuria.
If the obstruction was bilateral, increased diuresis occurs, sometimes for ten liters a day during the first few days.
Rarely has gradually increased diuresis, but does not reach values higher than 2-3 liters.
Oedema (if any) are revoked, the weight of patients is reduced, the heart is no longer with tachycardia.Blood pressure is normal, swelling of the liver is reduced, withdrawn signs caused by retention of water and salt. Polyuria last few days.
Removing obstacles can cause complications such reduction, and termination of diuresis (urine excretion) after initial polyuric crisis, the fall in blood pressure and other signs of collapse sudovnog - pallor, cold extremities, tachycardia, kilnićke signs of dehydration.
Rtg
Nativan footage kidney: renal shadows were increased in width and length. With the removal of barriers to reduce the size of the shadow and returns to normal values.
In cases of chronic kidney shadows could be reduced, uneven, with irregular edges, sometimes one part is more involved, or very reduced one half.
The cases of incomplete obstruction with preserved diuresis, "a large kidney" and if done it will be seen contrasting pyelogram distended pyelon, insufficient contrast, the slow and insufficient emptying of contrast. Cups are distorted, elongated, with unclear borders, maljičasto expanded. Papillae are not outlined, steeped in contrast to glass, glasses, and they lost their relief, and contractile ability. In extreme cases the pelvis is outlined, as a huge bag with polycyclic appearance due to the extreme outer edge of the expanded glass, with the kidney parenchyma, restricted to a thin membrane.
In some cases the bladder is defeormisana, enlarged, elongated, and the mouth of the urethra can be stretched, thinned, in the form of hooks.
In cases vezikalnog reflux, postmikcioni radiogram shows reflux of contrast into the ureters and even pyelon.
Biological criteria
laboratory:
Urinary Syndrome:
Proteinuria is usually minimal, rarely 1-2 gr 24 hours.
Urine Sediment: may be in the normal secretion of cell elements. More often abundant leukocyturia, and pyuria. Sterheimer-Malbin's cells.
Epithelial cells.
Leukocyte cylinders.
Microhematuria, usually less than quantitative leukocyturia. Makrohematurija rare, because lesions pijeluma, ureter, bladder, and rarely because of the intersticijelnog nephritis, or necrosis of the papillae. Makrohematurija is a regular at lithiasis, tumors, hydronephrosis.
Syndrome, renal failure:
Reduced kidney function due to global and glomerular lesions and tubular apparatus - the loss of nephrons.
Renal tubules predominates - the function of acidification of urine, obligatory polyuria, antidiuretic hormone-resistant; deficit concentration can be established before the signs of global renal insufficiency.
Dilution function was preserved.
The urinary losses of bicarbonate and sodium and insufficient secretion of NH4; acid value less than the titer for example. in patients with other forms of renal failure.
Reduced bicarbonate in plasma.
The reduction of plasma pH (metabolic acidosis if not fully compensated).
Plasma chloride is often increased to 110-115 m Eq / L 1 (characteristic of renal acidosis with relatively intact or less damaged than the glomerular tubular function). Acidosis with hiperhloremijom is often an early finding, before the establishment of severe global renal insufficiency. It can hardly be stated, but that is completely lacking.
Losses of sodium sometimes exceeding several grams per 24 hours, even in salt-free diet. Diabetes is extremely saline. This is caused by osmotic diuresis, glomerulotubularni imbalance, lesions proximal tubules.
Elevated creatinine, uric acid, phosphate, sulfate, is the same as in all renal failure.
Characteristics of urine in poliuričnoj stage after mechanical removal of obstacles:
Urine is izosmolarna plasma, the osmotic diuresis type, is obligatory, and it varies by degree of uremia, so that when one stops and reduce azotemia. It is even more intense if the glomerular filtration rate less damaged. The urine at this stage contains a lot of sodium, and potassium and a lesser degree.These losses are proportional to osmotic load and glomerular filtration. Lost and acids, but there is no alkalosis, because the patients at the time of removal prepereke always in metabolic acidosis.
Histology
The following changes are common to all intersticijeine nephritis:
Intersticium: the space between the nephron is expanded due to the presence of cellular infiltrates and fibrous tissue. These changes are expressed in the cortical area.
Cell infiltrate consisting of polymorphonuclear leukocytes, lymphocytes, plasma cells, histocita, or fibroblasts, whose nature depends on the etiology.
If the process is dominated by the more senior of infiltrating fibrotic changes and vice versa.
Glomeruli in fresh cases, glomeruli were unchanged, except in places where a particular cell infiltrate.In chronic cases develop characteristic changes are quite Bowman's capsule is thickened and it turned into concentric layers hijalne deployed. Capillary loops have preserved a normal structure. In the advanced stage of disease glomerular capillary klube being destroyed and replaced by fibrous tissue hijalnim where one can discern some of the capillary loop, or it is bezstrukturno, fibrosklerotično.Elsewhere, however, is completely preserved glomeruli.
Tubules in acute stages of tubule can have a normal appearance. In later development can be found that the tubule wall was destroyed and the lumen which creates leukocyte cylinders. Tubular epithelium becomes lower.
In the advanced stage of disease tubule lumen are broader: they contain colloid or hyaline cylinders, so that the image is reminiscent of the thyroid gland.
It is characteristic that changes in glomeruli and tubules are diffuse, even in chronic cases, so the next odmaklih sclerotic changes are found preserved glomeruli and tubules.
Blood vessels: the largest infiltration areas can be found thrombosis of medium-caliber arteries and veins.
Papilla: they are quite often affected by a variety of lesions. In cases with inflammation may develop suppuration papilla, in cases with obstruction may arise from foci of necrosis at the top of the papilla or deeper, which can be completely amputated, similar changes occur in chronic processes, particularly toxic, aseptic necrosis of ischemic papilla.
They can be affected by any structure, but the dominant changes in the interstitium of the changes in blood vessels and tubules. Finally, there are parts of a fully intact structure.
In cases of advanced evolution, changes are diffuse. In interstitial nephritis indicates inequality both kidneys, deep scars, extensive sclerosis, which go from the papilla to the cortex.
In cases of obstruction that led to aseptic hydronephrosis, the lesions may be minimal, but may be diffuse fibrosis, which replaces the destroyed nephrons and extending from the medulla to the surface, in cases of complete obstruction occurs quickly in the medulla citolitična necrosis at the top of the papilla either in the form of deeper trouble spots coalesce. Some pyramids are disappearing due to tissue necrosis. In the cortex, especially in the corticomedullary transition tubules are affected by degenerative changes and even necrosis of their epithelium.
Necrotic process and procedure of implantation with the formation of calix rupture allowing pijelointersticijelni reflux.
The blood vessels rupture resulting elastic and internal hijalinoza wall. In many vein thrombosis occurring. Intrarenalna venous route is highly expressed.
Functional criteria
There goes completely preserved function of excretion through the renal concentration, acidification of urine, to a global failure.
In the earlier stage of disease may be more affected than glomerular tubular function.
In cases of unilateral process of one kidney may be completely iskuljen from office, and yet there is no reduction in global function of excretion, if the other kidney is healthy.
The order for the diagnosis of nephritis obstruktivnog intersticijelnog
Anamnesis
pain when the typical - calculosis.
Clinic
enlarge the kidney, prostate, changes in urination - anuria, polyuria, retention phenomena.
Laboratory
Changes in the blood - in the case of failure, azotemia, urinary findings - kristaii, hematuria.
Rtg
changes in renal size, hydronephrosis, the exclusion of renal calculi findings, retrograde and intravenous pyelography. Evidence at reflux mikcionoj cystography.
Functional assessment:
greater tubular damage of glomeru-lar functions.
Urological examination the passing of the urinary tract.
Functional characteristics of
Obstructive interstitional nephritis may damage kidney function in the following ways:
• complete obstruction, interruption of excretion of both kidneys. The last acute uremia.
• complete obstruction of one kidney excretion functions can remain preserved the work of the second kidney.
• Partial obstruction of excretory tract of one or both kidneys with hydronephrosis and subsequent renal impairment because the appropriate zastojnog increasing pressure in the renal pelvis.
Other kidney function can compensate the injured party if the process is unilateral.
• interstitional nephritis has outbursts following functions:
First impaired secretion of global function, so that proportionately reduced and glomerumarna and tubular function. These are the cases with the destruction of a large number of nephrons.
Second greater impairment of tubular function than glomerular filtration,
Third decreased urine concentrating ability - hypotonic urine, resistant to the effects of pituitary antidiuretic hormone (compared with the degree of glomerular damage fiItracije this damage is greater in pyelonephritis than in other nephropathy.
• insufficient capacity for the excretion of acid urine (if there is no reduction in the secretion of global functions, this disorder can show only the probe loads NH4CI, it manifests a delay in the excretion of H ions, insufficient lowering of urine pH, which does not fall below 5 as in healthy people).
Insufficient secretion of NH4 ions.
There are urinary losses of bicarbonate and sodium, which results in the decrease in plasma bicarbonate. If metabolic acidosis is compensated, it may also be a reduction of plasma pH.
Cl ion plasma is elevated.
The result is hiperhloremija with acidosis.
In separate testing of urine can be concluded asymmetric damage functions (test probes or ureteral simpler method of scintigraphy, or isotopic renografije) ..
• In cases of obstruction, after removing the same, renal function can be preserved if the interruption of the secretion did not last long.
• If a mechanical delay lasted several days, is more damaged than the concentration ability of glomerular filtration.
• If complete obstruction lasting more than 3 weeks after the kidney is severely damaged barriers and removing obstacles osetnog not improve glomerular filtration, it remains very low.
• If the obstruction was complete 10-12 Sunday then it is definitely off the renal function.
• kidney after partial obstruction of the long-held if the second sound. Hiperpresija causing Oliguria, hiperosmolarnost, reducing sodium in the urine, a reduction in glomerular filtration rate of the same.
Hiperpresija, reflux of urine causes reversible functional impairment, but if the situation lasts for a long final result of kidney damage and related functional disorders.
• Incomplete obstruction of the urine output was held:
Glomerular filtration is normal or reduced.
PSP really low, especially compared with the clearance of urea and creatinine, which are correspondingly reduced. It dokazuie that there is an increase of urinary dead space, ie. obstacle to the excretory routes.
Hiperazotemija, acidosis, hiperhloremija, deshidratacija of renal water losses are the main humoral disorders incomplete obstruction that led to severe damage of glomerular and tubular function.
Function after the removal of obstacles if hiperpresija in the pelvis was the cause of renal failure:
Obligatory polyuria, dehydration, hypovolemia, hypo-or hyper-natremija.
After a few days will be set up and glomerualrna and tubular function, and sensitivity to antidiuretic hormone.
Depending on the degree of obstruction and its duration of outages behind definite function after mechanical removal of obstacles and causes increased pressure in the pelvis.
The minimum of the functional state testing program:
• urea and creatinine clearance.
• Concentration test.
• PSP test.
• The acid titer.
• Urology examination of urinary tract, pyelogram.
Forecast
Obstructive interstitional nephritis is a disease whose prognosis depends on the nature of the obstruction, the degree of obstruction and in particular the length of the obstruction.
Of importance is that when you remove the cause of obstruction, even if it led to Iezija that are no longer reversible, these lesions are losing evolutionary, progressive character.
If we remove the obstacles it is possible to quickly complete repair of tissue and restitutions functions.
If the obstruction is partial to one kidney, and other healthy, then the destruction of renal parenchyma is not progressing rapidly, but is inevitable.
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