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FEATURES OF THE COURSE OF CHRONIC PYELONEPHRITIS IN CHILDREN
AGAINST THE BACKGROUND OF ANEMIA
M.Sh.Ganieva,
D.S.Khodzhaeva
Andijan State Medical Institute
Relevance.
Anemia, being one of the manifestations of chronic kidney disease (CKD) in children,
is characterized by a decrease in the level of red blood cells and hemoglobin below normal
values [1]. In this case, anemia is usually normochromic, normocytic; with iron deficiency,
anemia is hypochromic, microcytic and hypoproliferative [2, 3].The cause of anemia
development in CKD is primarily a deficiency of erythropoietin (EPO) and iron, as well as a
number of other factors: a decrease in the lifespan of red blood cells (as a result of metabolic
acidosis), the content of EPO inhibitors in the blood, hemolysis, blood loss, hyperparathyroidism,
aluminum intoxication, increased activity of proteases and glycosidases, infections, and
disruption of hormonal homeostasis [1].
In addition to iron deficiency and erythropoietin deficiency, chronic inflammation,
hyperparathyroidism, vitamin B12 and folic acid deficiency, side effects of drug therapy (in
particular, angiotensin-converting enzyme inhibitors), etc. can be the causes of anemia in CKD
[1, 7, 8]. Many researchers also believe that L-carnitine deficiency, which destabilizes the red
blood cell membrane and reduces their survival, is the cause of anemia in CKD.
E. Costa et al. [31] found that patients treated with hemodialysis and not responding to therapy
with erythropoiesis-stimulating drugs had lower levels of serum albumin, lymphocytes, and
CD4+ cells compared to patients with an adequate erythropoietic response. These results
suggested a relationship between EPO resistance and the magnitude of the inflammatory
response [31]. The authors of the study showed that prohepcidin, soluble transferrin receptors in
the blood serum, and CPB are markers of anemia resistance to therapy with erythropoiesis-
stimulating drugs [32].
Purpose of the study:
to assess the impact of anemia on the course of chronic pyelonephritis in
children.
Material and research methods
. The study included 53 children treated in the nephrology
department of the Andijan Regional Medical and Medical Center from 2023 to 2024 at the age of
0 to 18 years. The control group consisted of 30 practically healthy children of the same age.
Table 1 shows the distribution of children by gender and age.
Table 1
No.
Chronic pyelonephritis (ChrPEN) (n=53)
Age
boys
girls
1
1-3 years
3
4
2
4 - 7 years
6
6
3
8 - 14 years old
3
19
4
15 - 18 years
old
1
11
Total(n=53)
13
40
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Distribution of patients with chronic pyelonephritis
From the data in Table 1 it is evident that in the group of children with Chronic PEN, girls
predominate, with the maximum distribution at the age of 8-14 years, although up to 7 years the
gender difference was minimal.
The average age of children in the group was
-
11.7±4.2. The
clinical diagnosis is made according to the ICD-X standards. This classification defines the form
of pyelonephritis (primary, secondary), the nature of the course (acute, chronic), activity and
state of renal function. In most cases, the examination revealed the secondary nature of this
disease
(dysmetabolic
nephropathy,
neurogenic
bladder,
VUR,
hypospadias,
ureterohydronephrosis). Only in 10 cases out of 53 cases, concomitant nephrological pathology
of obstructive and non-obstructive nature was excluded and the cause of urostasis was
indicated.
The chronization of the process was established on the basis of the duration of the
disease being more than 3 months. The duration of the disease in the examined children was on
average 6.2 years.
The diagnosis of chronic renal failure was made based on the anamnesis data, characteristic
clinical picture and confirmed by laboratory and instrumental studies. In this case, kidney
damage is manifested by one or more of the following signs: changes in the general blood test
(CBC), urine (UAM), feces, detection of changes in visualization methods of kidney
examination, urine culture with determination of the degree of bacteriuria and sensitivity to
antibiotics. Determination of the functional state of the kidneys was carried out based on a
biochemical blood test with determination of azotemia with subsequent calculation of the SCF.
Most of the observed patients lived in satisfactory housing and living conditions, however,
parents of 8.5% of children complained of poor housing and living conditions (poor apartment
amenities, cramped conditions, overcrowding, lack of sewage, etc.); 44.7% of the observed
patients were from large families (three or more children). In 7.2% of cases, mothers of sick
children had moderate forms of iron deficiency anemia during pregnancy, 10.5% of mothers
were diagnosed with nephropathy of pregnancy, 32.9% of the observed children with acute and
chronic pyelonephritis had a hereditary burden of urinary system diseases (urolithiasis,
pyelonephritis, glomerulonephritis in mothers or fathers, grandmothers or girls), 12.5% of
mothers of sick children suffered from chronic pyelonephritis.
As is known, the occurrence of pyelonephritis can be caused by various microorganisms
and microbial flora, as a rule, precedes and accompanies the disease. More than half of the
parents (61.2%) associated the occurrence of pyelonephritis in their children with an acute
respiratory disease, 27.6% - with cystitis, 11.8% with vulvitis, 1.3% with phimosis, which is
consistent with the literature data. (G. A. Majdrakov, N. Popov, 1980; E. Polachek et al., 2008; A.
I. Gnatyuk et al., 2009; Ya. Yu. Illek, 2013).
In the active period of acute and chronic pyelonephritis, upon admission to the hospital,
true pathological bacteriuria was detected in all observed children - 105 - 1012 microbial bodies
in 1 ml of urine. When sowing urine taken by catheter, staphylococcus was detected in most
patients - 55 (68.8%), much less often E. coli - 15 (18.7%) and Klebsiella - 10 (12.5%). Figure 1.
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Fig. 1. Results of urine cultures in patients with chronic
pyelonephritis.
The data we obtained correspond to the conclusions of a number of researchers (N.A. Lopatkin
et al., 2009; A.I. Gnatyuk et al., 2006; Ya.Yu. Illek, 2012) that the causative agent of
pyelonephritis in children in most cases is staphylococcus and E. coli. Before discharge from the
hospital, bacteriuria was not detected in the observed children with acute and chronic
pyelonephritis. The results of studies in the dynamics of clinical and laboratory parameters of
renal function in children with chronic pyelonephritis are presented in Table 2.
Table 2
Clinical and laboratory parameters in patients with chronic pyelonephritis [M±m]
Indicators
In
healthy
children
In
patients
with
chronic
pyelonephritis
Upon admission
Before discharge
Daily diuresis, ml
1179±31
1341±74
1247±87
Relative density of urine,
conventional units
1.019±0.0005
1.012±0.0005
1.019±0.0004
Urine protein, g/l
-avs
0.176±0.007
0, 033±0,01
Blood protein, g/l
67.4±1.0
60.0±0.6
63.7±0.6
Albumins, g/l
41.5±0.6
38.0±0.9
3.2±0.8
Globulins, g/l
25.9±0.7
26.8±0.7
25.8±0.7
Albumin/globulin index
1.66±0.07
1.41±0.08
1.48±0.07
Blood urea, mol/l
5.36±0.16
5.90±0.32
5.72±0.28
Residual nitrogen in blood,
mol/l
18.16±0.31
19.48±1.51
19.02±0.81
Blood creatinine, mol/l
0.069±0.002
0.073±0.004
0.070±0.002
Urine creatinine, mol/l
5.37±0.29
5.50±0.51
5.78±0.68
Creatinine excretion, mol/day
6.24±0.32
6.82±0.35
7.00±0.43
Creatinine clearance, ml/min.
104.32±2.14
96.96±3.54
100.00±2.47
Tubular water reabsorption, %
98.89±0.07
98.90±0.06
99.01±0.08
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As follows from the material presented in Table 2, in children with an exacerbation of
chronic pyelonephritis upon admission to the hospital and before discharge from the hospital, no
reliable changes in daily diuresis were noted. However, in the observed patients, a decrease in
the relative density of urine was noted in the first period of the study [P < 0.001]. An acidic urine
reaction was detected upon admission to the hospital in 94.1% of cases, and in the remaining
children with acute pyelonephritis and exacerbation of chronic pyelonephritis, the urine reaction
was alkaline. Upon admission to the hospital and during treatment, patients were recorded to
have a small and mild proteinuria, respectively, whereas before discharge from the hospital,
protein was not detected in the urine of the observed children.
All girls were examined by a pediatric gynecologist during their stay in the hospital. We divided
the identified pathology into 2 conditional groups: infectious diseases (vulvitis, vulvovaginitis,
colpitis) and other diseases (delayed sexual development, hypothalamic syndrome with
menstrual cycle disorders, oligomenorrhea, juvenile uterine bleeding, ovarian cysts,
hyperandrogenism of unknown genesis, erosion and pseudo-erosion of the cervix). When
determining the frequency of gynecological pathology in the groups, we found its higher
frequency in group I: for infectious pathology it was 7.7±3.3%, in group II only 3.0±1.1%.
One of the pathognomonic manifestations of renal pathology is anemia, which in adults
and children often takes on a severe course (Petrova K G, Vasiliev N, N., 1969; Tareev E. M.,
1972; Shulga Yu. D., 1973; Ignatova M. S., 1973; Javad-zade M. D., Malkov P. Cl, 1978;
Pukhlev A., 1980; Schwartz M. S., Steyskal J., 1980; Oan- ieli G. Mantroni V., 1966; Smith C.,
1969). The data obtained from the study of quantitative and qualitative parameters of peripheral
red blood and indicators of erythrocyte balance according to L.N. Mosyagina in children
observed by us with various clinical forms of chronic pyelonephritis without functional
impairment are presented in Table 2.
Table 2
Peripheral blood parameters in patients with chronic pyelonephritis (M±m)
Indicators
In
healthy
children (n= 30)
In patients with chronic pyelonephritis (n=
53)
Upon admission
Before discharge
Erythrocytes, 1012/l
4.23±0.03
3.55±0.06
3.82±0.06
Hemoglobin, g/l
123.2±1.1
106.9±1.3
108.1±2.3
Color indicator
0.89±0.01
0.84±0.02
0.850±0.01
Leukocytes, 10*9/l
6.72±0.17
9.33±0.50
8.51±0.42
Leukocyte formula,%:
Band neutrophils
3.1±0.2
5.3±0.9
3.3±0.4
segmented
55.1±1.0
54.4±2.1
56.6±2.1
lymphocytes
34.7±1.0
36.9±2.1
33.1±1.4
Eosinophils
2.3±0.2
4.8±0.5
2.8±0.3
Monocytes
4.8±0.3
4.6±0.3
4.2±0.3
ESR, mm/hour.
5.5±0.4
12.9 ±2.5
10.0±1.4
As can be seen from the data in Table 2, the children with chronic pyelonephritis we observed
had a significant decrease in the number of erythrocytes in the blood and an increase in the ESR
(P < 0.01-0.001) upon admission to the hospital and before discharge, in the absence of reliable
changes in the hemoglobin content in the blood and the color index value. However, in patients
with chronic pyelonephritis, the laboratory signs of anemia were more pronounced and persistent.
Along with this, in the observed patients, an increase in the total number of leukocytes in the
blood was recorded in the first two study periods (P < 0.001). Changes in the leukocyte formula
in the form of an increase in the percentage of band neutrophils in the blood (P < 0.01) were
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detected in children with acute pyelonephritis only upon admission to the hospital. The above
data indicate that we observed patients who had clinical manifestations and changes in clinical
and laboratory parameters characteristic of chronic pyelonephritis with preserved renal function.
When examining children with chronic PEN, we identified a number of features reflecting the
features of the pathological process against the background of anemic syndrome. When
clarifying the complaints and anamnesis of patients, we found that 20% of children (11) did not
present any complaints at the time of admission to the hospital - these patients were diagnosed
with mild anemia. In this regard, the 42 sick children included in the study were divided into 2
groups depending on the severity of anemia: Group 1 - children with chronic PEN + grade 2
anemia (35 children); Group 2 - children with chronic PEN + grade 3 anemia (7 children).
Chronic renal failure against the background of anemia was characterized by a higher frequency
of manifestations of the infectious symptom, and in children with severe anemia, signs of
intoxication in the form of fever, anorexia, general weakness, dyspepsia were more pronounced
and prolonged. The frequency of headaches associated with intoxication (they pass with the
improvement of the general condition, with the relief of fever, neurological pathology is
excluded during examination by a neurologist) in group I was 1.5 ± 0.5%, and in group II - 3.7 ±
1.6%. Fever in chronic renal failure was noted in children in group I in 3.8 ± 0.8% and in 6.7 ±
2.1% in group II.
The results of the assessment of general well-being significantly differed from the literature data,
which indicate a decrease in the quality of life and well-being with the association of Chronic
renal failure with anemia. In our study, complaints of impaired general well-being (weakness,
lethargy, fatigue, decreased appetite, decreased academic performance at school and tolerance to
physical activity) in the 1st group of children with anemia occurred in 5.9±2.0% of cases, while
in the 2nd group almost 2 times more often - 10.9±1.4% (p<0.05). We studied the absolute
number of complaints in children in the comparison groups taking into account the stage of the
disease, since a more severe impairment of renal function could affect the results of the study.
Children in group 1 had a greater number of complaints than in group 2. That is, in the early
stages, chronic renal failure against the background of anemia occurs more acutely, with a large
number of complaints, whereas in the later stages of the disease, general well-being primarily
determines the severity of the underlying process (Table 3).
Table 3
Total number of complaints upon admission in groups
The results of ultrasound examination of the kidneys were analyzed and are presented in Table 4,
where no significant differences were found. However, such an indicator of the chronic process
in the kidneys as compaction of the CEC is noted somewhat more often in Group I - 22.2±3.6 in
Group I and 17.3±1.7 in Group II. Results of ultrasound examination of the kidneys in children
of the comparison groups
Table 4
Chronic
PEN
and degrees of
anemia
0-1 complaint
2-3 complaints
More than 3 complaints
Group
I,
M±t, %
Group
II,
M±t, %
Group
I,
M±t, %
Group
II,
M±t, %
Group
I,
M±t, %
Group
II,
M±t, %
II degree
10.8±3.8
11.14=1.9 0
3.4±1.1*
1.5±1.5
0.4±0.4
III degree
13.8±4.3
23.3±2.6
7.7±3.3
4.2±1.2
1.5±1.5
0
Ultrasound data
Group I
I gr
II group
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Ultrasound results in study groups
In accordance with the standards of medical care in the hospital, all children with chronic
pathology underwent excretory urography and micturition urethrocystography to exclude
congenital organic pathology. Various pathologies of the bladder, urethra and VUR were
detected in
2.3±0.7
% of children in group I and 3.0±1.5% in group II. At the same time, the
absence of pathology according to the results of this examination was observed in group II -
43.7±4.3% significantly less frequently (p<0.05) than in group I - 55.7±2.2%. Pathology during
urography was detected in
13.3±2.9%
cases in group I and somewhat more often -
16.9±1.6%
in
group II. We studied the structure of organic kidney pathology based on excretory urography
data. Congenital pathology (expansion and deformation of the renal pelvis, tubular reflux,
achalasia of the renal pelvis, sclerosis of the renal tissue) in children of group I occurred with the
same frequency as in children without anemia, but manifestations of the chronic process in the
kidneys were noted in group I more often. Based on the data obtained, it can be concluded that in
group II the pathological process is characterized by greater activity, accompanied by more
pronounced damage to the kidney structure.
Thus, the data obtained in children of the two groups may indicate a more severe course of
chronic renal failure in combination with severe anemia and greater activity of the pathological
process.
If there were indications (complaints of pain in the right hypochondrium associated with the
intake of fried, fatty foods, increasing with physical activity, bitter taste in the mouth, unstable
stool; hepatosplenomegaly determined by palpation), children underwent additional ultrasound
of the hepatobiliary system. This study was conducted on 19 children of group I and 31 children
of group II. Pathology of the hepatobiliary system was more common in group II - 14.1 ± 3.0%,
while in group I only 6.0 ± 1.0% (p < 0.05). When examining the structure of this pathology, we
found out that its individual types were more common in children of group I. A combination of
different types of pathology was also more common in children of group II - 7.4 ± 2.3% - while
in group I more than 2 times less often - 2.9 ± 0.7% (Table 5).
Table 5
Results of ultrasound examination of the hepatobiliary system
Note * - p<0.05
Abs.
M±m, %
Abs.
M±m, %
Expansion of the ChLS
9
6.7±2.1
38
7.3±1.1
Compaction of the CEC
30
22.2±3.6
91
17.3±1.7
Nephroptosis
13
9.6±2.5
30
5.7±1.0
Decreased echogenicity of the renal
parenchyma
29
21.5±3.5
99
19.0±1.7
Congenital organic pathology of the
kidneys
12
8.9±2.4
42
8.1±1.2
Violationcorticomedullary differentiation
7
5.2±1.9
35
6.7±1.1
Test result
Group I
II group
Abs.
M±m, %
Abs.
M±m, %
Hepatomegaly
4
5.2±1.7
9
1.7±0.6
Violation of liver echostructure
5
4.4±1.8
11
2.1±0.6
Signs of pancreatopathy
6
7.4±2.3*
11
2.1±0.6
Gallbladder pathology
12
8.1±2.4
21
4.0±0.9
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Conclusions:
1.
In patients with chronic pyelonephritis, laboratory signs of anemia were more
pronounced and persistent; in the first two periods of the study, an increase in the total number of
leukocytes in the blood was recorded, which indicates the presence of a chronic infection.
2.
Chronic renal failure in combination with severe anemia occurs with greater activity of
the pathological process and is accompanied by more pronounced damage to the structure of the
kidneys.
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