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SYMPTOMS, DIAGNOSIS AND TREATMENT OF ACUTE INFLAMMATORY
KIDNEY DISEASES IN PATIENTS WITH DIABETES MELLITUS
Atoeva Munixon Nabievna
Bukhara State Medical Institute
Key words:
infections urinary paths, pyelonephritis, antibacterial drugs, tactics treatments
Symptomatology diagnosis and treatment of acute inflammatory renal diseases in diabetic
patients
Key words
: urogenital infections, pyelonephritis, antibacterial agents, therapeutic strategy
Diabetes mellitus ( DM), being one of the most common diseases in the world, is an acute
medical and social problem, priority for the health care systems of all countries [1].
Indisputable progress in the treatment of diabetes has led, on the one hand, to an increase in
the life expectancy of these patients, and on the other hand, to an increase in the frequency
of various complications of this disease. Disruption of carbohydrate metabolism has a
negative impact on almost on All organs And systems organism, V volume including the
genitourinary system. Among the main urological complications at SD most often meet
infections urinary tract infections (UTIs) and closely related inflammatory diseases kidneys.
Peculiarities development And currents IMP at sick SD
One from main specific processes at SD is increase concentrations glucose V urine on
background hyperglycemia .
Glucosuria is one from most important risk factors
development IMP at patients With SD V result suppression of phagocytosis And, Maybe,
cellular immunity, A Also contributing
adhesion bacteria, Although V experiment Very
high con- centration glucose V urine (over 55 mmol/l) suppresses their growth. In final as a
result, long-term expressed glucosuria is a risk factor for damage to the serous- mucoid layer
of the urothelium with the development of UTI. Pathogenetic factors that cause development
IMP And inflammatory diseases kidneys in diabetes, are also [2, 3]:
toxic effects of hyperglycemia;
micro- And macroangiopathy , contributing renal ischemia ;
autonomic neuropathy leading to neurogenic bladder dysfunction and chronic urinary
retention ;
flaw glycogen, leading To deterioration nutritional conditions of the glomerular-tubular
apparatus;
hyperglycemia, which reduces the phagocytic activity of leukocytes and the bactericidal
activity of the blood.
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At SD1 development IMP promotes long-term course of the disease, more early (V flow
first 4–5 years) And persistent development of peripheral and autonomic neuropathy. [4].
Spectrum pathogenic microorganisms, provocative IMP in patients with diabetes mellitus is
similar to that in patients without diabetes mellitus [5]. It has been established that diabetes
mellitus increases the risk of developing acute pyelonephritis (AP) ascending from the lower
urinary tract, the causative agent of which is representatives of the genus Enterobacteriaceae
and Enterococcus faecalis . Often at women, suffering SD, V this roles perform also
representatives genus Klebsiella (25% at patients With SD By compared to 12% in patients
without diabetes) [7].
A number of established bacterial factors are related to the virulence of a bacterial cell and
its ability to attach to the surface of the mucous membrane before the moment of its
introduction. clutches, so-called fimbriae . Fimbriae 1 type are present in almost all types of
Escherichia Coli , which provide binding to receptors of vaginal mucosa cells, And V lesser
degrees With receptors protective mu - copolysaccharide layer lining the mucous membrane
of the urinary tract . . For bacteria with type 2 fimbriae (P- fimbriae ), a tendency to adhere
to glycolipids of substances of various blood groups that are secreted by the urothelium is
more characteristic . P- fimbriae , in contrast to type 1 fimbriae , are more degrees have
ability To clutch And defeat urinary tract , causing UTI and pyelonephritis. In the studies of
A. Hopelman , S. Geerlings (2000), an increase in the adhesion of E. coli with type 1
fimbriae to the uroepithelium of women with diabetes was revealed compared to healthy
people [8].
Important factor protection macroorganism from infection is the level of sex hormones, in
particular: estrogens and progesterone for women, and testosterone for men. The urothelium
produces and secretes onto the surface a mucopolysaccharide substance that forms an
adhesive protective layer. The formation of this mucopolysaccharide layer is considered a
hormonally dependent process: estrogens affect its synthesis , progesterone on his selection
epithelial cells [9]. Confirmed Also And role testosterone V impact on urothelial receptors .
It has been shown that in patients with diabetes, against the background of decreased levels
of sex hormones, there is an increased risk of developing UTI [10, 11, 12].
Spicy inflammatory diseases kidneys at sick SD
Inflammatory diseases of the kidneys include acute pyelonephritis (AP) and chronic
pyelonephritis (CP), which can be either a consequence of AP or an independent form of the
disease. AP is determined How infectious and inflammatory disease of the renal parenchyma
and renal pelvis with predominant defeat interstitial fabrics. Long- term decompensation
carbohydrate exchange is risk factor development And progression acute infectious -
inflammatory process in the kidneys, however, pyelonephritis itself is not complication SD.
OP And his chronization are factors that aggravate the course of such a formidable specific
complication as diabetic nephropathy.
Special attention clinicians addressed on acute purulent-destructive forms of the course of
OP, due to the rapid progression of the disease and a real danger to life sick V cases
development septic states. In case obstructions urinary paths (stones kidneys And
ureters , tumor urinary bubble, adenoma prostate And etc.) algorithms diagnostics And
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treatments IMP radically change , That's why these cases demand separate consideration.
OP in patients with diabetes can be either asymptomatic (in case of immune system
areactivity , or partial immunity) moon deficit), So And leak manifestly [14]. It is believed
that decrease common immune resistance predisposed -
Gaet To persistence pathogens IMP [15].
In non-obstructive OP, microorganisms reach the urinary tract hematogenously or through
the lymphatic pathways [16]. It has been established that What sick SD especially vulnerable
For rapid progression infections V renal parenchyma And her subsequent complications.
The combination of diabetes and OP leads to the emergence of a vicious circle, when the
active inflammatory process in the renal parenchyma negatively affects the function of the
glomerular-tubular apparatus, simultaneously aggravating insulin deficiency due to the
increase in acidosis. In turn, metabolic disorders and a clear decrease in microcirculation
worsen the course of purulent infection in the kidneys, What received Name "syndrome
mutual burdens " (Fig. 2) [17] .
An additional factor that aggravates the development of AP is endothelial dysfunction,
which, against the background of prolonged exposure to hyperglycemia, leads to disruption
of angiogenesis and hemostasis [18]. In this case, there is a decrease in the synthesis of NO
And increase concentrations endothelin-1 V renal vessels, What V result leads To their
spasm, platelet aggregation, adhesion of mono- and platelets. Decompensated diabetes is
often accompanied by a state of immunodeficiency, in which infectious processes occur
more aggressively. Maybe, By this reason development of OP is Not so many result
aggression microorganisms, but rather as a result of the state of the macroorganism
predisposing it to infection [19].
AP often occurs as a severe infectious disease that poses a threat to the patient's life.
Conflicting data on the clinical features, course of the disease and insufficient studied
mechanisms development OP at sick
With SD determine difficulties his diagnostics,
treatments and prevention. On sectional material OP is revealed at 20% of patients with
diabetes mellitus who died from various other causes, i.e. who did not have a primary
diagnosis of AP [20].
In patients with diabetes, as in the general population, a unilateral inflammatory process
predominates. However, with severe decompensation of diabetes, the risk of developing
bilateral pyelonephritis increases . As a rule, the clinical onset of the disease is acute - with
high temperature, fever, dysuria , pain in the lumbar region. Leukocytosis and an increase in
ESR are noted in the blood . In patients with diabetes, urine testing reveals the presence of
bacteria and a large number of leukocytes , however , in this category of patients, a normal
cellular composition of urine sediment and the absence of bacteriuria.
In typical cases, diabetes mellitus affects the upper urinary tract, up to the development of a
diffuse-purulent ( apostematous pyelonephritis ) or purulent-destructive form of the disease
(carbuncle, abscess). The frequency of development of purulent forms is proportional to the
severity of the course and the degree of carbohydrate metabolism disorder . exchange.
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In typical cases, diabetes mellitus affects the upper urinary tract, up to the development of a
diffuse-purulent ( apostematous pyelonephritis ) or purulent-destructive form of the disease
(carbuncle, abscess). The frequency of development of purulent forms is proportional to the
severity of the course and the degree of carbohydrate metabolism disorder . exchange.
In at least a third of patients, OP manifests itself in the form of a purulent process:
apostematous pyelonephritis, carbuncle or abscess. It is known, What V 34% cases at sick
without SD OP turns into purulent forms [21]. If diagnosis is not made in a timely manner ,
And belated therapy diseases at patients on background of diabetes, acute serous
pyelonephritis develops into purulent forms in most patients [22]. In these cases, the disease
is accompanied by severe intoxication and, if not treated in a timely manner, treatment
Maybe develop septic shock, in which mortality exceeds 60% [23, 24, 25]. In diabetes
mellitus , a powerful infectious process can become a prerequisite for the rapid development
of pyogenic infection. Patients with diabetes mellitus are prone to the development of rarely
diagnosed interstitial nephritis of an unusual form - nephritis caused by gas-forming
microorganisms and accompanied by a high mortality rate (emphysematous pyelonephritis).
Histologically, it is characterized by acute pyogenic infiltration with the formation of
microabscesses and a high risk of further development of acute renal failure ( ARF). The
route of penetration of these microorganisms can be hematogenous. Even in the absence of
obstacles outflow urine sharp infection V parenchyma is capable of progressing unnoticed
until the development of intrarenal abscess, With distribution on perirenal fiber. It should be
especially noted that emphysematous infection of the urological tract occurs almost always
and only among patients with diabetes [13], and is a life-threatening condition , mortality at
this form reaches 90% [26].
Difficulties V identification OP at SD arise V connections With the absence of pronounced
local symptoms, and partly masking the clinical picture of AP by severe manifestations
diabetes. Erased painful syndrome at sick With long -term decompensated SD And fever
unclear genesis, in the absence of changes in urine tests, is the basis for a urological
examination to exclude OP [27]. In patients with diabetes, the presence of OP may not be
established at normal cellular composition urine, absence bacteriuria , proteinuria. A similar
complex situation can be observed at apostematous pyelonephritis, carbuncle and abscess
without drainage of purulent exudate into the renal pelvis and calyces . Therefore, it is
necessary to use all available laboratory capabilities and modern radiation methods of
examination (MRI) for timely diagnosis.
Traditionally diagnostics OP is based on accounting result -
of a comprehensive examination, including data from the anamnesis , clinical picture of the
disease, laboratory and radiation methods research. Position With diagnostics OP has
improved significantly with the advent of new high - tech diagnostic funds, such How
ultrasonic and - research (ultrasound) and multi-spiral computed tomography (MSCT).
These methods have changed the understanding of the possibilities of diagnostics of
inflammatory kidney diseases. It has been established that early radiation diagnostics of
purulent forms of OP at SD belongs main role V recognition pathological process, A Also
V establishment stages And forms of the disease, V dynamic observation at conservative
therapy and monitoring the condition of organs (kidneys and surrounding tissues ) [28].
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Antibacterial therapy for AP should be started without delay . Empirical therapy involves
choosing antibiotics that are active against the most common pathogens of this type of
infection. According to the recommendations of the European Association of Urologists
(2008) for the treatment of urinary tract infections, patients with pyelonephritis at the stage
of purulent inflammation are recommended to be treated with fluoroquinolones ,
aminopenicillins with
- lactamase inhibitors , second- and third-generation
cephalosporins, and aminoglycosides. However , it is known that the use of aminoglycosides
in patients with diabetes mellitus, V connections With their expressed nephrotoxicity ,
possible only in exceptional cases and under careful control - lem of kidney function.
Special place V treatment OP occupy carbapenems . By According to the European
Association of Urologists (2008), this group of drugs has super wide spectrum actions:
active in relation majority gram-positive, literacy - negative And anaerobic microorganisms.
That's why They are drugs second rows at treatment heavy forms of inflammatory processes
of the urinary tract. In our opinion, at development OP at sick With SD, V separate cases,
carbapenems can apply And How drugs first row.
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