DIFFERENTIAL
DIAGNOSIS OF INFECTIOUS AND INFLAMMATORY DISEASES OF THE URINARY SYSTEM IN CHILDREN.
URINARY TRACT
INFECTION
A urinary tract infection (UTI)
is an infection of the bladder and sometimes the kidneys. If the bladder is
infected, it is called cystitis. If the kidneys are
infected, it is called pyelonephritis. It is important
to treat UTIs so that the kidneys are not damaged.
Various symptoms are possible:
Ø painful
urination
Ø an
urgent need to urinate
Ø frequent
urination
Ø daytime
and nighttime wetting
Ø dribbling
Ø foul-smelling
urine
Ø fever
Ø stomachaches
(especially lower abdomen)
Ø vomiting.
Causes
Urinary tract infections
are caused by bacteria. The bacteria enter the bladder by traveling up
the urethra. In general, the urethra is protected, but
if the opening of the urethra (or the vulva in girls) becomes irritated,
bacteria can grow there. Common irritants are bubble bath and shampoos.
Careless wiping after a bowel movement might also cause irritation. A rare
cause of UTIs (1% of girls and 5% of boys) is obstruction of the urinary tract,
which results in incomplete emptying of the bladder. Children who start and
stop their stream of urine while they are going to the bathroom are more likely
to get a UTI.
Duration
With
treatment, your child's fever should be gone and symptoms should be better by
48 hours after starting the antibiotic. The chances of getting another UTI are
about 50%. Read the advice on preventing UTIs to decrease your child's risk.
Treatment
Antibiotics
Encourage child to drink extra fluids
to help clear the infection.
Fever and pain relief
Give child acetaminophen (Tylenol) or
ibuprofen (Advil) for the painful urination or for fever over
Many children who get
urinary tract infections have normal kidneys and bladders. But if a child has
an abnormality, it should be detected as early as possible to protect the
kidneys against damage.
Abnormalities that could occur
include the following:
Þ Vesicoureteral reflux (VUR).
Urine normally flows from the kidneys down the ureters to the bladder in one
direction. With VUR, when the bladder fills, the urine may also flow backward
from the bladder up the ureters to the kidneys. This abnormality is common in
children with urinary infections.
Þ Urinary
obstruction. Blockages to urinary flow can occur in many places in the urinary
tract. The ureter or urethra may be too narrow or a kidney stone at some point
stops the urinary flow from leaving the body. Occasionally, the ureter may join
the kidney or bladder at the wrong place and prevent urine from leaving the
kidney in the normal way.
Þ Dysfunctional
voiding. Some children develop a habit of delaying a trip to the bathroom
because they don’t want to leave their play. They may work so hard at keeping
the sphincter muscle tight that they forget how to relax it at the right time.
These children may be unable to empty the bladder completely. Some children may
strain during urination, causing pressure in the bladder that sends urine flowing
back up the ureters. Dysfunctional voiding can lead to vesicoureteral
reflux, accidental leaking, and UTIs.
Pyelonephritis is an
ascending urinary tract infection that has reached the pyelum
(pelvis) of the kidney (nephros in Greek). If the
infection is severe, the term "urosepsis"
is used interchangeably (sepsis being a systemic inflammatory response syndrome
due to infection). It requires antibiotics as therapy, and treatment of any
underlying causes to prevent recurrence. It is a form of nephritis. It can also
be called pyelitis.
Urinary tract infections
(UTIs) are common in the pediatric age group. Early recognition and prompt
treatment of UTIs are important to prevent progression of infection to pyelonephritis
or urosepsis and to avoid late sequelae
such as renal scarring or renal failure.
Causes
Most cases of
"community-acquired" pyelonephritis are due to bowel organisms that
enter the urinary tract. Common organisms are E. coli (70-80%) and Enterococcus
faecalis. Hospital-acquired infections may be due to
coliforms and enterococci, as well as other organisms uncommon in the community
(e.g. Klebsiella spp., Pseudomonas aeruginosa). Most cases of pyelonephritis start off as
lower urinary tract infections, mainly cystitis and prostatitis.
Risk is increased in the following situations:
Mechanical: any
structural abnormalities to the kidneys and the urinary tract, vesicoureteral reflux (VUR) especially in young children,
calculi (kidney stones), urinary tract catheterisation,
urinary tract stents or drainage procedures (e.g. nephrostomy), neurogenic
bladder (e.g. due to spinal cord damage, spina
bifida.
Constitutional: diabetes
mellitus, immunocompromised states
Positive family history
(close family members with frequent urinary tract infections)
Infants and young
children with UTI may present with few specific symptoms. Older pediatric
patients are more likely to have symptoms and findings attributable to an
infection of the urinary tract. Differentiating cystitis from pyelonephritis in
the pediatric patient is not always possible, although children who appear ill
or who present with fever should be presumed to have pyelonephritis if they
have evidence of UTI.
It presents with dysuria
(painful voiding of urine), abdominal pain (radiating to the back on the
affected side) and tenderness of the bladder area and the side of the involved
kidney (costovertebral angle tenderness) which may be
elicited by performing the kidney punch. In many cases there are systemic
symptoms in the form of fever, rigors (violent shivering while the temperature
rises), headache, and vomiting. In severe cases, delirium may be present.
Severe cases of
pyelonephritis lead to sepsis, a systemic response to infection characterized
by fever, a raised heart rate, rapid breathing and decreased blood pressure
(occasionally leading to septic shock). When pyelonephritis or other urinary
tract infections lead to sepsis, it is termed urosepsis.
Pathophysiology
UTIs generally begin in
the bladder due to ascending infection from perineal
contaminants, usually bowel flora such as Escherichia coli. In neonates,
infection of the urinary tract is assumed to be due to hematogenous
rather than ascending infection. This etiology may explain the nonspecific
symptoms associated with UTI in these patients.
The causative agents of
urinary tract infections in hospitalised infections
show a different distribution from those that occur in the community...
Norm Pyelonephritis
Normal and pyelonephritic
kidneys
Acute pyelonephritis is an
exudative purulent localized inflammation of the renal pelvis (collecting
system) and kidney. The renal parenchyma presents in the interstitium
abscesses (suppurative necrosis), consisting in
purulent exudate (pus): neutrophils, fibrin, cell debris and central germ
colonies (hematoxylinophils). Tubules are damaged by
exudate and may contain neutrophil casts. In the early stages, glomeruli and
vessels are normal. Gross pathology often reveals pathognomonic radiations of
hemorrhage and suppuration through the renal pelvis to the renal cortex.
Chronic infections can result in fibrosis and scarring.
Xanthogranulomatous pyelonephritis is a form of chronic pyelonephritis
associated with granulomatous abscess formation and severe kidney destruction.
Hospital patients:
·
Escherichia coli: 40%
·
Coagulase-negative staphylococci: 3%
·
'Other' Gram-negative bacteria: 25%
·
'Other' Gram-positive bacteria: 16%
·
Candida albicans: 5%
·
Proteus mirabilis: 11%
Community-acquired Urinary Tract Infections:
·
Escherichia coli: 80%
·
Coagulase-negative staphylococci: 7%
·
'Other' Gram-negative bacteria: 4%
·
'Other' Gram-positive bacteria: 3%
·
Proteus mirabilis: 6%
Gram-negative bacteria
other than Escherichia coli causing
urinary tract infections, particularly in hospitalised
patients, commonly include Klebsiella spp., Enterobacter spp., Serratia spp. and Pseudomonas
aeruginosa.
After the neonatal
period, bacteremia generally is not the cause of UTI. The bladder is the
initial primary locus of infection with ascending disease of the upper tract
(kidneys) and bacteremia as potential sequelae.
Bacterial invasion of the bladder with overt UTI is more likely to occur if
urinary stasis or low flow conditions exist. Some causes of these conditions
are infrequent or incomplete voiding, reflux, or other urinary tract
abnormalities.
Even in the absence of
urinary tract abnormalities, cystitis causes vesicoureteral
reflux, and it may worsen preexisting reflux. Reflux may cause development of
pyelonephritis. Chronic or recurrent pyelonephritis results in renal damage and
scarring that may progress to chronic renal failure if it continues or is
severe.
Etiologic structure of pyelonephitis in children
Etiologic structure of lower urinary
infections in children
E.coli
Frequency: Prevalence varies based on age and sex.
Mortality/Morbidity:
Generalized bacteremia or
sepsis may develop from UTI. Approximately 30% of 1- to 3-month-old infants
with UTIs are at risk for developing sepsis. The risk drops to approximately 5%
in patients older than 3 months.
If left untreated, simple
cystitis may progress to pyelonephritis. More severe cases have the potential
for kidney damage, which may lead to hypertension or renal insufficiency.
Approximately 5-10% of
children with symptomatic UTI and fever develop renal scarring.
Sex: Uncircumcised males have a higher incidence than
circumcised males. Uncircumcised male infants have a higher incidence of UTI
than female infants.
UTIs are more frequent in
females than males at all ages with the exception of the neonatal period,
during which UTI may be the cause of an overwhelming septic syndrome in male
infants younger than 2 months.
Incidence is highest in
sexually active adolescent females.
Age: Excluding neonates, females younger than 11 years have
a 3-5% risk; boys of the same age have a 1% risk.
UTI is the source of
infection in up to 6-8% of febrile infants. Conversely, approximately the same
number of febrile infants are bacteremic (considering
all sources, including UTI).
CLINIC
Symptoms:
·
flank pain or
back pain,
·
severe
abdominal pain (occurs occasionally),
·
fever,
·
chills with
shaking,
·
warm skin,
flushed or reddened skin, moist skin (diaphoresis),
·
vomiting,
nausea,
·
fatigue,
general ill feeling,
·
painful
urination, increased urinary frequency or urgency, need to urinate at night (nocturia), cloudy or abnormal urine color, blood in the
urine, foul or strong urine odor,
·
dental
changes or confusion.
History:
Neonates
·
Jaundice
·
Hypothermia or fever
·
Failure to thrive
·
Poor feeding
·
Vomiting
Infants
·
Poor feeding
·
Fever
·
Vomiting, diarrhea
·
Strong-smelling urine
Preschoolers
·
Vomiting, diarrhea, abdominal pain
·
Fever
·
Strong-smelling
urine, enuresis, dysuria, urgency, frequency
School-aged children
·
Fever
·
Vomiting, abdominal pain
·
Strong-smelling
urine, frequency, urgency, dysuria, flank pain or new enuresis
Physical:
·
Hypertension
should raise suspicion of hydronephrosis or renal
parenchyma disease.
·
Costovertebral angle (CVA) tenderness
·
Abdominal tenderness or mass
·
Palpable bladder
·
Dribbling,
poor stream, or straining to void
·
Examine
external genitalia for signs of irritation, pinworms, vaginitis, trauma, or
sexual abuse.
Prompt
diagnosis of kidney infections in small children is important to prevent complications
such as kidney scarring or the development of a blood stream infection. The
symptoms of kidney infection in babies are nonspecific, meaning they do not
point directly to the kidney as the source of the infection. As children reach
the toddler stage, the symptoms of kidney infection become more specific to the
urinary system.
Fever is a characteristic symptom of kidney
infection in young children. Especially among youngsters who are not yet
talking, a fever lasting more than 48 hours may be the prominent feature of the
illness. The fever associated with kidney infection is typically higher than
100.4 degrees Fahrenheit. Notably, an abnormally low body temperature may
indicate infection in a newborn. A temperature which ispersistently
lower than 97.7 degrees Fahrenheit despite attempts to warm the baby may
indicate a kidney or other serious infection.
Diagnosis
Typical clinical features include urgency, frequency, burning during
urination, dysuria, nocturia, and hematuria
(usually microscopic but may be gross). Urine may appear cloudy and have an ammoniacal or fishy odor. Other
common symptoms include a temperature of 102° F (38.9° C) or higher, shaking
chills, flank pain, anorexia, and general fatigue.
A history and physical exam will be performed. Blood
and urine tests will be done to identify the infection and cultures of the
urine can isolate the infecting bacteria. If a kidney stone is suspected a CT
scan must be done.
The diagnosis of pyelonephritis can usually be made by history, physical
examination, and laboratory tests. Imaging may be necessary when the diagnosis
is in question, when there are recurrent infections, or if the patient responds
poorly to appropriate antibiotic therapy after three days. Computed tomography
(CT) with intravenous (IV) contrast is the test of choice when evaluating the
urinary tract. The most common CT finding in pyelonephritis is wedge-shaped
lesions of decreased attenuation with or without swelling. Anatomic
abnormalities and perinephric abscesses can also be
seen on contrast-enhanced scans. Renal ultrasound is also used to evaluate the
collecting system and pyelonephritis and may show ureteral dilation, suggesting
obstruction. Although renal ultrasound is helpful, a CT scan is more sensitive.
Magnetic resonance imaging may be used in patients who are allergic to
iodinated contrast.
The
presence of nitrite and leukocytes (white blood cells) on a urine dipstick test
in patients with typical symptoms are sufficient for the diagnosis of
pyelonephritis, and are an indication for empirical treatment. Formal diagnosis
is with culture of the urine; blood cultures may be needed if the source of the
infection is initially doubtful.
Acute pyelonephritis (renal biopsy)
Micropreparations
of kidney in acute purulent pyelonephritis:
colonies of microorganisms
(blue) in the renal tubules.
Nuclear Medicine Software Suite
The HERMES DMSA Analysis program is
primarily designed to help detect the onset of pyelonephritis in young children
and to monitor the effect of treatment on infected patients. The program
compares the function of each kidney with the function for a database of
reference cases in order to assist detection of abnormal function.
Diagnosis
requires urinalysis and culture. Typical findings include:
❑ pyuria (pus in urine) —
urine sediment reveals the presence of leukocytes singly, in clumps, and in
casts; and, possibly, a few red blood cells
❑ significant bacteriuria —
more than 100,000 organisms/µl of urine revealed in urine culture
❑ low specific gravity and osmolality, resulting from a
temporarily decreased ability to concentrate urine
❑ slightly alkaline urine pH
❑ proteinuria, glycosuria, and keto-nuria
— less common.
X-rays
also help in the evaluation of acute pyelonephritis. X-ray films of the
kidneys, ureters, and bladder may reveal calculi, tumors,
or cysts in the kidneys and urinary tract. Excretory urography may show
asymmetrical kidneys.
If a kidney stone is suspected (e.g. on the basis of characteristic
colicky pain, disproportionate amount of blood in the urine), X-rays of the
kidneys, ureters and bladder (KUB) may assist in identifying radioopaque stones.
Abdominal
radiograph in a 3-year-old child. This image shows a right staghorn calculus.
Intravenous urogram in a 3-year-old child. This image
shows normal function/excretion on the left, but no function is detectable on
the right. A diagnosis of xanthogranulomatous
pyelonephritis was confirmed at surgery.
This delayed nephrogram phase
of a subtraction-selective right renal angiogram shows an avascular lower renal
mass. A diagnosis of focal xanthogranulomatous
pyelonephritis was confirmed at surgery.
Contrast-enhanced computed tomography scan
through the mid poles of the kidneys. This image shows a staghorn calculus
within the right renal sinus that is associated with mild hydronephrosis,
thinning of the cortex, and areas of low attenuation surrounding the calculus.
The patient presented with pyrexia and leukocytosis. Ultrasonographic examination revealed a perinephric
fluid collection, which was drained percutaneously
(not shown). Note the air in the retroperitoneum
after percutaneous drainage. At subsequent surgery, xanthogranulomatous
pyelonephritis was confirmed.
In patients with recurrent ascending urinary tract infections, it may be
necessary to exclude an anatomical abnormality, such as vesicoureteral
reflux (urine from the bladder flowing back into the ureter) or polycystic
kidney disease.
Investigations that are commonly used in this setting are ultrasound of
the kidneys or voiding cystourethrography.
Lab Studies:
Urinalysis
A urine specimen that is
found to be positive for nitrite, leukocyte esterase, or blood may indicate a
UTI.
Microscopic examination
can evaluate for presence of WBCs (5 per high-power field), RBCs, bacteria,
casts, and skin contamination (eg, epithelial cells).
A midstream clean catch
is appropriate if the patient is old enough to cooperate. Clean skin around the
urethral meatus and allow first urine to go into the toilet; then, collect the
specimen in a sterile collection cup. Collection may be easier if girls sit
facing the toilet.
A bag specimen is
adequate for specific gravity. The specimen may be used if the urine bag is
removed immediately after urine is deposited. (These specimens are really only
useful if results of the urinalysis are negative.)
Urine culture
Urine cultures should be
sent to the laboratory even if urinalysis results are inconclusive.
Results are best
interpreted with knowledge of the collection method and results of the
urinalysis.
A clean-catch urine
sample with more than 100,000 colony-forming units (CFU) of a single organism
is classic criteria for UTI.
Judgment must be used in
interpreting a clean-catch specimen that reports any growth. If the specific
gravity of the urine was low, 60,000-80,000 CFU may be significant.
Lower colony counts may
be significant if present on a repeat culture. Contamination with perineal flora may mask an existing UTI.
Urinary tract
abnormalities may be associated with multiple organisms.
Cultures with growth of
more than 10,000 CFU from bladder catheterization or suprapubic aspiration
should be considered significant for UTI.
Cultures from bagged
urine specimens are significant only if there is no growth.
Better results may be
obtained if the perineum is cleaned and dried before the bag is placed and if
the collected urine is removed as soon as the patient voids.
Electrolyte abnormalities may be present.
An increased blood urea
nitrogen (BUN) finding in a child older than 2 months should raise suspicion of
hydronephrosis or renal parenchyma disease.
Here is an example of an
interstitial parenchymal disease. This is acute pyelonephritis. The irregular
pale, raised lesions you see on the surface are collections of purulent exudate
in the superficial cortex.
Acute suppurative
pyelonephritis
This is a cross-section of a
piece of a kidney showing acute suppurative
pyelonephritis. The white streaks running through the medulla and the white
blotches in the cortex represent purulent exudate in the tubules and in the
interstitial tissue.
Chronic pyelonephritis
This is an example of
chronic pyelonephritis. Repeated bouts of suppurative
inflammation in the cortex have resulted in widespread scarring as seen on the
left, and a diminution in the overall cortical mass as seen on the right.
Treatment
As practically all cases of pyelonephritis are due to bacterial
infections, antibiotics are the mainstay of treatment. Mild cases may be
treated with oral therapy, but generally intravenous antibiotics are required
for the initial stages of treatment.
The type of antibiotic depends on
local practice, and may include fluoroquinolones
(e.g. ciprofloxacin), beta-lactam antibiotics (e.g. amoxicillin or a
cephalosporin), trimethoprim (or co-trimoxazole).
Aminoglycosides are avoided due to their toxicity, but may be added for a short
duration.
A 10-day course of antibiotics is recommended, even
for uncomplicated infection. It must not be used short-course therapy in
children because it is more difficult to differentiate cystitis from
pyelonephritis.
Drug Category: Antibiotics
- Empiric antibiotics should be chosen for coverage of E.coli
and for Enterococcus, Proteus, and Klebsiella
species. For suspected pyelonephritis, a combination of parenteral antibiotics
is recommended. Ceftriaxone is considered adequate therapy for an occult UTI in
the febrile patient. For uncomplicated cystitis, oral antibiotic therapy is generally
adequate.
|
Drug Name |
Ampicillin (Omnipen, Principen)- Provides
bactericidal activity against susceptible organisms. Administered parenterally and used in combination with gentamicin or cefotaxime. |
|
|
|
|
Pediatric Dose |
100-200 mg/kg/d IV/IM
divided q6h |
|
Contraindications |
Documented hypersensitivity |
|
|
Probenecid and disulfiram elevate
levels; allopurinol decreases effects and has additive effects on ampicillin
rash. |
|
|
|
|
Precautions |
Hypersensitivity reaction; caution in
cephalosporin allergy. |
|
Drug Name |
Gentamicin (Garamycin)- Aminoglycoside antibiotic for gram-negative
coverage. Provides synergistic activity with ampicillin against gram-positive
bacteria including enterococcal species. Inhibits
protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes.
Dosing regimens are numerous; adjust dose based on CrCl
and changes in volume of distribution. May be administered IV/IM. |
|
Pediatric Dose |
<5 years: 2.5 mg/kg/dose
IV/IM q8h |
|
Contraindications |
Documented hypersensitivity;
non–dialysis-dependent renal insufficiency |
|
Interactions |
Coadministration with other aminoglycosides, cephalosporins,
penicillins, and amphotericin B may increase
nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents
thus prolonged respiratory depression may occur; coadministration
with loop diuretics may increase auditory toxicity of aminoglycosides;
possible irreversible hearing loss of varying degrees may occur (monitor
regularly) |
|
Precautions |
Narrow therapeutic index
(not intended for long-term therapy); caution in renal failure (not on
dialysis), myasthenia gravis, hypocalcemia, and
conditions that depress neuromuscular transmission; adjust dose in renal
impairment |
|
Drug Name |
Cefotaxime (Claforan)-
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy
against gram-positive organisms. For septicemia and treatment of gynecologic
infections caused by susceptible organisms. Arrests bacterial cell wall
synthesis, which, in turn, inhibits bacterial growth. |
|
Pediatric Dose |
100-200 mg/kg/d IV/IM
divided q6-8h |
|
Contraindications |
Documented hypersensitivity |
|
Interactions |
Probenecid may increase levels; coadministration
with furosemide and aminoglycosides may increase nephrotoxicity |
|
Precautions |
Adjust dose in severe renal
impairment; has been associated with severe colitis; caution in penicillin
allergy |
|
Drug Name |
Amoxicillin (Amoxil, Trimox)- Interferes
with synthesis of cell wall mucopeptides during
active multiplication, resulting in bactericidal activity against susceptible
bacteria. Activity against gram-positive and some gram-negative
bacteria. |
|
Pediatric Dose |
30-50 mg/kg/d PO q8h |
|
Contraindications |
Documented hypersensitivity |
|
Interactions |
Reduces the efficacy of PO
contraceptives |
|
Precautions |
Adjust dose in renal
impairment; caution in cephalosporin allergy |
|
Drug Name |
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)-
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic
acid. Antibacterial activity of TMP-SMZ includes common urinary tract
pathogens, except Pseudomonas aeruginosa. |
|
Pediatric Dose |
<2 months: Not
recommended |
|
Contraindications |
Documented hypersensitivity;
megaloblastic anemia due
to folate deficiency |
|
Interactions |
May increase PT when used
with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone
may increase blood levels of both drugs; coadministration
of diuretics increases incidence of thrombocytopenia purpura
in elderly persons; phenytoin levels may increase with coadministration;
may potentiate effects of methotrexate in bone marrow depression;
hypoglycemic response to sulfonylureas may increase with coadministration;
may increase levels of zidovudine |
|
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
|
Precautions |
Discontinue at first
appearance of skin rash or sign of adverse reaction; obtain CBCs frequently;
discontinue therapy if significant hematologic changes occur; goiter,
diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV
infusions or high doses may cause bone marrow depression (if signs occur,
administer 5-15 mg/d leucovorin); caution in folate
deficiency (eg, persons with chronic alcoholism,
elderly persons, those receiving anticonvulsant therapy, those with
malabsorption syndrome); hemolysis may occur in individuals with G-6-PD
deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ;
caution in renal or hepatic impairment (perform urinalyses and renal function
tests during therapy); give fluids to prevent crystalluria
and stone formation |
During the course of antibiotic treatment,
serial white blood count and temperature should be closely
monitored. Typically, the IV antibiotics should be continued till the
patient is afebrile for at least 24 to 48 hours, then equivalent oral
antibiotic agents can be given for a total of 2-week duration of treatment.
Intravenous fluids may be
administered to compensate for the reduced oral intake, insensible losses (due
to the raised temperature) and vasodilation and to maximize urine output.
I.V. antibiotics are used
initially to control bacterial infection. Chronic pyelonephritis may require
long-term antibiotic therapy. Commonly used antibiotics include sulfa drugs,
amoxicillin, cephalosporins, levofloxacin, and
ciprofloxacin. Urinary analgetics such as phenazopyridine
are also appropriated. Symptoms may disappear after several days of antibiotic
therapy. Although urine usually becomes sterile within 48 to 72 hours, the
course of such therapy is 10 to 14 days.
In recurrent infections, additional
investigations may identify an underlying abnormality. Occasionally, surgical
intervention is necessary to reduce chances of recurrence. If no abnormality is
identified, some studies suggest long-term preventative (prophylactic)
treatment with antibiotics, either daily or after sexual intercourse. In
children at risk of recurrent UTIs, meta-analysis of the present literature
indicates that not enough studies have been performed to conclude prescription
of long-term antibiotics have a net positive benefit. Ingestion of cranberry
juice has been studied as a prophylactic measure; while studies are
heterogeneous, many suggest a benefit.
Cranberry juice
Some recommend other
nutritional approaches to prevent recurrence of UTIs. Increasing fluid intake,
consuming cranberry juice, blueberry juice, and fermented milk products
containing probiotic bacteria, have been shown to inhibit adherence of bacteria
to the epithelial cells of the urinary tract.
Blueberry juice
Probiotics
Probiotics are described as a kind of
existing bacteria that is like the healthy or good bacteria that is produced by
the human body. It is acquired chiefly
in a type of dietary supplements as well as some types of food. It is also considered beneficial as a
substitute therapy in health care. But it is not regarded as a component of
standard treatment.
As of the present, probiotics are
very popular among individuals who want to maintain a good balance in their
digestive system. It is considered that
these live microorganisms that can be obtained in the favorite health store can
give a lot of health benefits if patient has problems in his digestive tract.
This statement is especially true if probiotics is taken in sufficient amounts.
CYSTITIS
Cystitis is inflammation of
the bladder due to an infection or irritation. Usually cystitis only affects
bladder and is known as a lower urinary tract infection (UTI). If the infection
goes higher this can be a more serious illness known as an upper urinary tract
infection.
Urine infection in children is
common. It can cause various symptoms. A course of antibiotics will usually
clear the infection quickly. In most cases, a child with a urine infection will
make a full recovery with no ongoing concerns. Following the infection, tests
to check on the kidneys and/or bladder are advised in some cases. The doctor
must advise these tests. It depends on factors such as the child's age, the
severity of the infection, and whether it has happened before.
Risk factors
In most cases -
no
Most urine infections in children are just 'one of those things' and
there is no underlying problem to account for it.
In some cases 'retention' of urine in the urinary
tract may play a part.
When we pass urine, the bladder
should fully empty. This helps to flush out any bacteria that may have got into
the bladder since the last toilet trip. However, various abnormalities of the
urinary tract can make the urine stay around in the bladder, ureters or kidney
- when it should be travelling down the ureters and emptying completely out of
the bladder when going to the toilet. This may allow any bacteria that get
there to multiply as urine is a good 'food' for some bacteria. Various
situations can cause some 'retention' of urine in the bladder or higher in the
urinary tract, which increases the chance of developing a urine infection.
The following are the most common:
Ø Constipation
If large hard faeces
(stools) collect in the rectum (back passage) they can press on the bladder.
The bladder may then not empty fully when the child passes urine. Treating
severe constipation sometimes prevents recurring urine infections.
Ø Dysfunctional
elimination syndrome
This is a condition where a young
child repeatedly 'holds on' to urine and/or faeces.
That is, they regularly do not fully empty their bladder or rectum when they go
to the toilet. There is no physical cause for this (that is, no abnormality in
the urinary tract or rectum). The reason why this occurs is often unclear.
Stress or emotional problems may be the underlying cause.
Ø An
abnormality of the urinary tract
Various abnormalities of the urinary
tract can cause retention of some urine. The most common condition is called 'vesico-ureteric reflux'. This is a problem at the junction
where the ureter enters the bladder. In this condition, urine is passed back
(refluxes) up the ureter from the bladder from time to time. This should not
happen - the urine should only flow downwards out of the bladder when going to
the toilet. This condition makes urine infections more likely. Also, infected
urine that refluxes from the bladder back up to the kidneys may cause kidney
infection, scarring, and damage. In some cases this leads to severe kidney
damage if urine infections recur frequently. Other rare problems that may be
found include kidney stones, or congenital abnormalities of parts of the
urinary tract.
Ø Neurological
(nerve) or spinal cord disorders
-Anything that affects the bladder
emptying or sensation. These are rare in children.
Ø Other
conditions
Other conditions that increase
the risk of a urine infection include having diabetes, and a poorly functioning
immune system. For example, children with are having chemotherapy.
CAUSES
Infectious agents to penetrate
into the bladder in various ways:
• rising - from the urethra
and the anogenital area;
• falling - from the kidney
and upper urinary tract;
• lymphogenous
- from adjacent pelvic organs;
• haematogenous
- in the septic process;
• contact - contact with
microorganisms through the wall of the bladder from adjacent foci of
inflammation.
Symptoms of
cystitis
Young children, toddlers and babies can
have various symptoms which may include one or more of:
·
Fever
(high temperature)
·
Vomiting
and/or diarrhea
·
Drowsiness
·
Crying,
going off feeds and generally unwell
·
Appear
to be in pain
·
Blood
in urine (uncommon)
·
Jaundice
(yellowing of the skin)
·
Cloudy
or smelly urine
Cystitis can
be painful, particularly when you pass urine, but it usually clears up within
four to nine days.
Older children, in addition to
one or more of the above symptoms, may also say that they have pain when they
pass urine, and pass urine frequently. If a kidney becomes infected they may
also have shivers, and complain of abdominal (tummy) pain, back pain, or a pain
in a side of the abdomen. Bedwetting in a previously 'dry' child is sometimes
due to a urine infection. Just being 'generally unwell' may be due to a urine
infection.
Diagnosis
A sample of urine is needed to confirm
the diagnosis. Urine normally has no bacteria present, or only very few. A
urine infection can be confirmed by urine tests that look for bacteria and/or
the effects of infection in the urine.
Ideally,
the sample of urine should not come into contact with skin or other materials
that may contaminate it with other bacteria. Older children can do this by a 'mid stream' collection of urine. This is not easy to do in
young children and babies.
The following are ways to
get a sample of urine that is not contaminated:
Young
children - the usual way is to catch some urine in the specimen bottle whilst
in 'full flow'. Just be ready with the open bottle as the child passes urine.
(Be careful not to touch the open rim of the bottle with your fingers as this
may contaminate the specimen with bacteria from your fingers.)
Babies
- one method is to place a specially designed absorbent pad in a nappy
(supplied by a doctor). Urine is sucked into a syringe from the wet pad.
Another method is to use a plastic bag that sticks onto the skin and collects
urine. If no pad or plastic bag is available, the following might work. Take
the nappy off about one hour after a feed. Tap gently with a finger (about once
a second) just above the pubic bone. (This is the bone at the bottom of the
abdomen above the genitals.) Have the open bottle ready. Quite often, within
about five minutes, the baby will pass urine. Try and catch some in the bottle.
Bacteriuria
Cystoscopic
pattern of cystitis
Hyperdistention of bladder during A small, reddish-brown spot on
the
cystoscopy, showing glomerulations bladder mucosa, called a Hunner's ulcer
(arrow), visible during cystoscopy
(pinpoint hemorrhages or bleeding
fissures). of the
bladder.
USD
Echo sings of cystitis
Treatment
A course of an antibiotic will
usually clear the infection within a few days. Give lots to drink to prevent
dehydration. Also, give paracetamol to ease any pains
and fever (high temperature). Sometimes, for very young babies or for severe
infections, antibiotics are given directly into a vein through a 'drip'.
Therapy
of acute cystitis in children should be directed to:
• The elimination of pain
• Normalization of urination
disorders
• Elimination of
microbial-inflammatory process in the bladder
Drug treatment of acute
cystitis and uretritis involves the use of
antispasmodic, uroseptic and antibacterial medicines.
When pain syndrome is severe the use of no-spani,
belladonna, papaverin are useful.
Cystitis is treated with antibiotic drugs.
Antibiotics will be prescribed for at least 2 to 3 days and perhaps for as long
as several weeks. The length of the treatment depends on the severity of the
infection and on the personal history.
However, it is important that the patient completes the entire course of
medication. Otherwise, the infection is likely to return. Urine must be checked
after the finish taking the antibiotic. This is to make sure that the infection
is truly gone.
If it is experience of recurrent
infections, the doctor may prescribe stronger antibiotics or take them for a
longer period of time. It may be also recommend to take low-dose antibiotics as
a preventive measure.
Pyridium is a
medicine that decreases pain and bladder spasms. Taking pyridium
will turn your urine and sometimes your sweat an orangish
color.
Prognosis
In most cases, the outlook is
excellent. Once a urine infection is diagnosed and treated, the infection
usually clears away and the child recovers fully. In many cases, a urine
infection is a 'one-off' event. However, some children have more than one urine
infection and some develop several throughout their childhood ('recurring
UTIs').
In some cases, an infection can be
severe, particularly if a kidney becomes badly infected. This can sometimes be
serious, even life threatening in a minority of cases if treatment is delayed.
A bad infection, or repeated infections, of a kidney may also do some permanent
damage to the kidney. This could lead to kidney problems or high blood pressure
later in life.
Further tests
Urine infection is common. In most
cases, a child with a urine infection will make a full recovery with no ongoing
concerns.
Tests
are advised in some cases to check on the kidneys and/or bladder. It depends on
factors such as the child's age, the severity of the infection, and whether it
has happened before.
Children over the age of six
months who have a 'one off' urine infection which promptly clears with
treatment do not usually need any further tests.
Children with a severe
infection, or with an infection with unusual features, may warrant tests.
Children with recurring
infections of any severity may warrant tests.
The tests that are advised may
vary depending on local policies and the child's age. There are various tests
(scans, etc) that can check on the structure and
function of the urinary tract (the kidneys, ureters, bladder and urethra).
The results of the tests are
normal in most cases. However, in some cases, an abnormality such as vesico-ureteric reflux may be detected. Depending on
whether an abnormality is detected, and how severe it is, a kidney specialist
may advise a regular daily low dose of an antibiotic. This treatment is advised
in some cases to prevent further urine infections, with the ultimate aim of
preventing damage to the kidneys.
Urethritis
Urethritis
is when the opening of the urethra (tube where the urine comes out) is
irritated. When this happens, the area outside the vagina (vulva) is usually
irritated as well (vulvitis). This problem almost
always occurs before puberty.
The
symptoms can include:
·
Discomfort, stinging, or burning when
urinating.
·
Feeling an urgent and frequent need
to urinate.
·
Itching and pain in the genital area.
Causes
Irritation by chemicals in bubble bath, shampoo,
or soap that was left on the genital area is almost always the cause before a
child reaches puberty.
5% of young girls do get urinary tract infections
(UTI), which can cause the same symptoms. A UTI is a bacterial infection of the
bladder (cystitis) and sometimes the kidneys. UTIs must be treated by health
care provider.
Diagnosis
Prevention
Recommendation
to mother
§ Wash
the genital area with water, not soap.
§ Don't
use bubble bath before puberty. Don't put any other soaps or shampoo into the
bath water. Don't let a bar of soap float around in the bathtub. If you are
going to shampoo your child's hair, do this at the end of the bath.
§ Keep
bath time less than 15 minutes. Have your child urinate immediately after
baths.
§ Teach
your daughter to wipe herself correctly from front to back, especially after a
bowel movement.
§ Encourage
her to drink enough fluids each day to keep the urine light colored.
§ Encourage
her to urinate at least every 4 hours during the day.
§ Have
her wear cotton underpants. Underpants made of synthetic fibers (polyester or
nylon) don't allow the skin to "breathe." Discourage wearing
underpants during the night.
Treatment
Antibiotics
are given to treat urinary tract infections. A child may begin to feel better
soon after starting the antibiotic. But it is very important to finish taking
the full course of antibiotics. If kidney abnormalities are found, further
treatment may be needed.
Some children have to be admitted to the hospital for treatment. This is
needed if a child is extremely ill, or is unable to keep down liquids or take
antibiotics. Very young children may need to be admitted for intravenous
antibiotics. Sometimes an older child does not get better on antibiotics by
mouth and will also need an intravenous antibiotic.
A
variety of drugs may be prescribed based on the cause of the patient's
urethritis. Some examples of medications based on causes include:
ü Clotrimazole (Mycelex) - Trichomonial
ü Fluconazole
(Diflucan) - Monilial
ü Metronidazole
(Flagyl) - Trichomonial
ü Nitrofurantoin - Bacterial
ü Nystatin (Mycostatin) - Monilial
ü Co-trimoxazole, which is a combination of Sulfamethoxazole
and Trimethoprim in a ratio of 5 to 1 (Septrin, Bactrim)
- Bacterial
Uncomplicated
UTIs can be diagnosed and treated based on symptoms alone. Oral antibiotics
such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone
such as ciprofloxacin substantially shorten the time to recovery still about 50
% of women will recover without treatment within a few days or weeks. The
Infectious Diseases Society of America recommends a combination of trimethoprim
and sulfamethoxazole as a first line agent in
uncomplicated UTIs rather than fluoroquinolones.
Resistance has developed in the community to all of these medications due to
their widespread use.
A three-days
treatment with trimethoprim, TMP/SMX, or a fluoroquinolone
is usually sufficient while nitrofurantoin requires 7
days. Trimethoprim is often recommended to be taken at night to ensure maximal
urinary concentrations to increase its effectiveness. While trimethoprim / sulfamethoxazole was previously internationally used (and
continues to be used in the U.S. and Canada); the addition of the sulfonamide
gives little additional benefit compared to the trimethoprim component alone.
It is responsible however for a high incidence of mild allergic reactions and
rare but potentially serious complications. For simple UTIs children often
respond well to a three-day course of antibiotics.
Phenazopyridine can help
with painful urination.
Differential diagnosis of pyelohephritis and low urinary infections
|
Sings |
Pyelonephritis |
Low urinary
infections |
|
Fever more than 38,5°Ñ |
+ |
– |
|
Leukocytosis |
+ |
– |
|
Increasing of ESR more than 35mm/hr |
+ |
– |
|
Increasing of concentration function of kidneys |
+ |
– |
|
Proteinuria and aminoaciduria |
+ |
– |
|
Asymmetrical damage of kidney |
+ |
– |
Dysmetabolic nephropathy
Dicmetabolic
nephropathy (DN) is a group of diseases with different etiology and
pathogenesis, characterized by interstitial process with the defeat of the
tubules of the kidneys due to metabolic disorders. In a broad sense any DN is
associated with various metabolic diseases that lead to changes in renal
function or structural changes at the level of the various elements of the
nephron.
Any DNs are
characterized by the glut of urine or other substances and urinary syndrome in
the form of crystalluria.
Etiopathogenic mechanisms are represented by various
factors both endogenous and exogenous nature.
Endogenous factors:
- Hyperfunctioning parathyroid glands
-
Hyper-and hypovitaminosis
-
Violation of electrolyte homeostasis (K, Ca, Mg)
-
Diabetes mellitus
- Urate
nephropathy
-
Oxalate nephropathy
-
Metabolic cystine
-
Violation of the exchange of tryptophan
-
Genetic predisposition
-
Tissue dysembriogenesis
Exogenous
factors:
-
Especially food
-
Especially drinking water treatment
- Ecopatogeny
-
Drugs
-
Climatic features of the region
The vast majority of crystalluria and DH are related to calcium (70 to 90%),
about 85-90% of them - with oxalates (in the form of calcium oxalate), the
other with phosphates (calcium phosphates - 3-10%) or are mixed - oxalate
(phosphate)-urate. Urate crystalluria and litiaz are up
about 5% of cases, cystine - up to 3%.
In 5-15% of cases there are tripelphospates: phosphate crystals containing ammonium
ion, magnesium and calcium.
The common features
characterizing dysmetabolic nephropathy is a glut of
urine, uric syndrome in a crystalluria, the presence
of salt inclusions in pyelocaliceal system.
Clinics and Diagnostics
In children under 5 years
old there are no specific symptoms. In older children: fatigue, abdominal pain,
characterized by fluid retention in the body, which is manifested eyelid edema,
decrease in the amount allocated urine, stabbing pains in the back. Often there
are itching, pain and redness in the external genitalia. Urine turbid, with the
sediment on the walls of the pot is formed which is difficult washed away
plaque.
Metabolic disorders of oxalates
DN with the oxalate-calcium crystalluria (oxalate nephropathy) is poly etiology
disease, based on a violation of the stability of renal cytomembranes
both the hereditary and sporadic. According to different authors, the
proportion of genetic factors in the development of oxalate nephropathy is up
to 70-75%. In addition to genetics, environmental factors have an important
role: diet, stress, environmental stress, etc.
Oxalate-calcium crystalluria occurs most frequently in childhood. Its
pathogenesis may be related to the violation of both the exchange of calcium
and exchange oxalates. The majority of patients with oxalate-calcium crystalluria have no
disturbances of metabolism of oxalate or increases of its excretion in
the urine, but there is hypercalciuria. Crystals of
calcium oxalate can be formed and at a normal level of calcium in the urine is
due to increased content of oxalates.
Oxalates enter the body through
food or exogenously produced endogenously. Oxalate completely filtered in the
glomeruli and then reabsorbed and secreted in the tubules. Even a slight
increase in the number of oxalate in the urine is due to their high ionic
strength of the high probability of calcium oxalate.
Causes of
Oxalate-calcium crystalluria:
•
hereditary defects of some enzymes
•
high intake of oxalates from food
•
inflammatory bowel disease
•
deferred bowel surgery
• Crohn's disease
•
Ulcerative Colitis
•
deficiency of vitamin B6
•
Excessive consumption of ascorbic acid
Phosphate crystalluria
Primary or true phosphaturia occurs in diseases involving a violation of
phosphorus and calcium metabolism. The main cause of secondary phosphaturia is a chronic infection of the urinary system.
Of particular importance in this regard there are micro-organisms with urease
activity. Urease breaks down urea in the urine alkalization, which leads to supersaturation of urine magnesium and ammonium phosphate.
Connection struvite with carbon appatitom
in different quantities leads to the formation tripelphosphatnic
crystals.
Phosphaturia
can also develop as a result of violations of calcium metabolism in hypercalciuria, and the crystals are mainly calcium
phosphate. Often, calcium phosphate crystalluria
oxalate-calcium accompanies, but less pronounced.
Frequency phosphate crystalluria is in the overall structure dismetabolic nephropathy 5-15%. Increased renal excretion
of phosphate is due to a number of complex pathogenic mechanisms.
Clinics
In patients
with phosphaturia there is intensely turbid urine,
containing a significant amount of salts and phosphates resembles in appearance
diluted milk. Phosphaturia is often accompanied by
stomach ulcers and duodenal ulcers, chronic gastritis with elevated gastric
acidity, diabetes and several other diseases. This phosphaturia
is secondary, as opposed to primary, existing as an independent disease.
Phosphaturia
is characterized by frequent formation of loose, easy break up stones.
Uric nephropathy
Metabolic uric acid is the
basis of urate nephropathy due to the influence of
sodium salt of uric acid in renal tissue. The frequency of urate
crystalluria in the structure of dismetabolic
nephropathy ranges from 5 to 26%.
Causes of uraturia:
•
hereditary reasons (defect of the renal tubules, enhanced exchange of purines)
•
increased consumption of meat products
• treatment
of chemotherapy
•
long term administration of furosemide
Etiopthogenic
features of urate crystalluria
are associated with an increased synthesis and increased excretion of uric acid
by a number of pathological conditions.
The examination program for dismetabolic
nephropathies
1.
Clinical-anamnestic examination:
-
Genealogical analysis
-
Integrated assessment of lifestyle the child, the nature of power,
environmental factors
-
Evaluation of comorbidity
-
Persistent crystalluria in history
2.
Laboratory and instrumental examinations:
-
General clinical analysis of urine
-
Study of the functional state of tubular apparatus (test Zimnitski,
titratable acidity, the reaction of urine, etc.)
-
Bacteriological examination of urine
-
Biochemical study of blood:
a)
the concentrations of calcium, uric acid, phosphates
b)
the level of creatinine
c)
calculations of GFR (glomerular filtration rate)
-
Daily excretion of salt (transport of salts)
-
AMCEN (anticristal ability of urine) to calcium
oxalate, calcium phosphate and triplephosphates
-
Test on calciphylaxia
-
Test for peroxide in the urine
-
Calculation of indices "calcium / creatinine", "uric acid /
creatinine", "phosphorus / creatinine
-
Ultrasonography of the urinary and digestive systems
Treatment
Treatment of any DN can be reduced to four
basic principles:
·
normalization of life
·
correct drinking regime
·
diet
·
specific methods of therapy
Normalization of lifestyle,
physical and mental health is an important condition for achieving a positive
effect in the treatment of DN. Pronounced and prolonged violations of these
components ultimately realized in microcirculatory abnormalities, leading to
hypoxia and / or the direct injurious effects on cells. All this will intensify
and / or exacerbate violations of cellular metabolism, lipid peroxidation of
membranes, their instability, etc.
Drinking a lot of fluid is a
universal treatment for all DNs, since it reduces the concentration of soluble
substances in the urine. Also important is receiving fluids, especially during
periods of peak daily concentrations of urine, ie,
during sleep. Therefore, one of the goals of healing is nocturia,
which is achieved by fluid intake before bedtime. Preference should be given to
a simple or mineral water, as prolonged intake of fluids, for example,
acidifying the urine or contain carbohydrates can cause increased excretion of
calcium.
Diet in the treatment of oxalaturia
It should be allowed:
Different cabbages, potatoes,
bananas, melons, pears, pumpkins, cucumbers, peas, all kinds of cereals, white
bread, vegetable oil.
It should be limited:
·
Carrots, green beans, chicories,
tomatoes, strong tea, beef, chickens, liver, blackberry and redcurrant, red
apples and radish.
It should be excluded:
Chocolate,
beet, celery, spinach, sorrel, rhubarb, parsley, extractives broths.
Diet in the
treatment of phosphaturia
It should be allowed:
Butter, vegetable, rice, semolina,
pasta, flour, cabbages, potatoes, carrots, cucumbers, beets, tomatoes,
apricots, watermelon, pears, plums, strawberries, cherries.
It should
be limited:
Beef, pork, sausage, boiled egg, corn
grits, flour, second grade, milk, sour cream.
It
should be excluded:
Cheese, cottage cheese, liver, beef,
chicken meat, fish, eggs, beans, peas, chocolate, barley, oat, barley,
buckwheat, millet.
Diet in the treatment of uraturia
It
should be allowed:
Potato-cabbage diet is the
main. Dairy products must be done in the
first half of the day. Colored and white cabbage, cereals (buckwheat, oats,
millet, rice), fruits, dried apricots, prunes, seaweed, wheat bran, butter and
vegetable oil, white bread, rye whole meal. Meat and fish without fat should be
given 3 times a week 150g, the older children in boiled form in the first half
of the day.
It
should be limited:
·
Peas, beans, beef, chicken, rabbit.
It should be excluded:
·
Strong tea, cocoa, coffee, chocolate,
sardines, liver, fatty fish, meat and fish broth.
Medications
Drug therapy includes membranotropic
drugs and antioxidants. Treatment should be prolonged. Antibacterial therapy is
indicated for accession infection.
Pyridoxine (vitamin B6) is
administered at a dose of 1-3 mg / kg / day (400 mg / day) for 1 month on a
quarterly basis. Vitamin B6 has membranes action by participating in the
exchange of fats as an antioxidant and an exchange of amino acids. It is also
appropriate use of the drug magneV6 rate of 5-10 mg / kg / day rate for 2
months 3 times per annum.
Membranes action is provided by
vitamin A, which is embedded in bilipidny layer and
normalizes the interaction of proteins and lipid membranes. The daily dose of
vitamin A 1000 IU for one year of life, the course - 1 month on a quarterly
basis.
Tocopherol
acetate (vitamin E) is a powerful antioxidant, which enters the body from the
outside and is produced endogenously. It must be remembered that the exogenous
administration of vitamin E may inhibit the endogenous production by the
mechanism of negative feedback. Vitamin E enhances the protein-lipid bonds
cellular membranes. Vitamin A is assigned in a dose of 1-1,5mg / kg / day.
For membranostabilization
there are used dimephosphon and xidiphon.
Dimephosphon restores the connection between
oxidation and phosphorylation in cellular respiration, which occurs during
dissociation of instability of the mitochondrial membranes, interrupting the
cascade processes of lipid peroxidation. It is used in a dose of 1 ml of 15%
solution for every
Xidiphon
is complex drug, which facilitates the inclusion of calcium in the mitochondria
and prevents the deposition of its insoluble salts. It is prescribed in a dose
of 10 mg / kg / day of 2% solution in 3 divided doses. Course - 1 month, 2
times a year.
Cystone has
the high efficiency, especially when crystalluria. Cystone is assigned a dose of 1-2 tablets 2-3 times a day
rate of 3 to 6 months.
In addition, magnesium oxide is
appointed, especially at primary hyperoxaluria, in a
dose of 0,15-0,2g / day. In primary hyperoxaluria any
therapy is palliative.
At hyperuricemia
it is important to reduce the concentration of uric acid up to 6 mg/100 ml or
less. For this purpose reducing the synthesis of uric acid - inhibitors of
xanthine oxidase should be done. The use of allopurinol in pediatrics is
limited because of possible complications - Hepatitis, epidermal necrosis,
alopecia, leuko-and thrombocytopenia, increased
xanthine in the blood. Under the strict supervision of allopurinol is
prescribed in doses of 0,2-
Nicotinamide
is a weaker inhibitor of xanthine oxidase than allopurinol, but better
tolerated, is appointed at a dose of 0,005-0,025g 2-3 times a day for 1-2
months of repeated courses. Colchicine reduces the transport of purine bases
and their rate of exchange. Appointed at a dose of 0,5-2 mg / day for a period
of 18 months to several years.
Uricozuric
effect is characteristic for the of orotic acid, Cystone, Etamid, tsistenal, Phitolizin etc.
Potassium orotate tablets are appointed in a dose of
10 mg / kg / day in 2-3 reception for 1 month. Benzbromaron,
which is used in dose 50-100 mg / day 2-3 times in combination with sodium
citrate and saluretics has olso
uricozuric and uricostatic
action.
Treatment with the phosphate crystalluria should be directed to the acidification of
urine (mineral water, drugs: cystenal, ascorbic acid,
methionine).
At expressed excretion of calcium
phosphate it is necessary to decrease the absorption of phosphorus and calcium
in the gut (for example, appointment almagel). An
obligatory component of treatment there are antibacterial therapy and treatment
of chronic infections of the urinary system.
Main recommendations:
regime
diet
membranes and antioxidant therapy
rehabilitation in local sanatoriums
spa treatment at the resorts
Criteria for the
effectiveness:
absence of crystalluria
absence of changes in the biochemical analysis of urine
absence of change in the ultrasound or a positive trend
absence of acute pyelonephritis
The most frequent complication
of DN is the developing of urinary tract infections, particularly
pyelonephritis. However, it should be noted that the detection of NAM on the
background of pyelonephritis is impossible to reliably establish a primary or
secondary to pyelonephritis is DN.
The prognosis for secondary
DN is generally favorable. In most cases, the appropriate regime, diet and
medication can achieve stable normalization of the indicators in the urine. In
the absence of treatment or when it is ineffective most natural outcomes of the
DN are urolithiasis and interstitial nephritis.
Referens:
A - Basic:
1. Pediatrics. Textbook. / O. V. Tiazhka, T. V. Pochinok, A. N.
Antoshkina et al. / edited by O. Tiazhka
– Vinnytsia : Nova Knyha
Publishers, 2011 – 584 pp. : il.
2. ISBN 978-966-382-355-3Nelson
Textbook of Pediatrics, 19th Edition Kliegman,
Behrman. Published by Jenson & Stanton, 2011, 2608.
ISBN: 978-080-892-420-3.
3. Illustrated Textbook of Paediatrics,
4th Edition. Published by Lissauer & Clayden, 2012, 552 p. ISBN: 978-072-343-566-2.
4. Denial Bernstein. Pediatrics for
medical Students. – Second edition, 2012. – 650 p.
2. http://www.merckmanuals.com/professional/index.html