Intersticial nephrite

Description:

The Intersticial Nephrite (IN) represents an inflammatory disease of kidneys of the noninfectious (abacterial) nature with localization of pathological process in interstitial (intersticial) fabric and defeat of the canalicular device of nephrons. It is an independent nosological form of a disease. Unlike pyelonephritis at which interstitial fabric and renal tubules are also surprised intersticial nephrite is not followed by destructive changes of renal fabric, and inflammatory process does not extend to cups and a pelvis. The disease is for the present poorly known to practical doctors.

Clinical diagnosis of intersticial nephrite even in specialized institutions of a nephrological profile presents great difficulties due to the lack of clinical and laboratory criteria, characteristic, pathognomonic only for it, and also in connection with its similarity to other forms of a nephropathy. Therefore the most reliable and convincing diagnostic method of IN is the puncture biopsy of a kidney so far.

As in the conditions of clinical practice of IN it is diagnosed still rather seldom, still there are no exact data on the frequency of its distribution. Nevertheless, according to the data which are available in literature, for the last decades the explicit tendency to growth of frequency of this disease among adult population is noted. It is connected not only with improvement of diagnostic methods of IN, but also with broader impact on kidneys of those factors which serve as the reason of its emergence (especially medicines) (B. I. Shulutko, 1983; Ya. P. Zalkalns, 1990, etc.).

Distinguish the acute Intersticial nephrite (AIN) and the chronic Intersticial nephrite (CIN), and also primary and secondary. As at this disease not only intersticial fabric, but also tubules is always involved in pathological process, along with the term "intersticial nephrite" consider competent to use also the term "tubulointerstitsialny nephrite". Primary IN develops without the previous any damage (disease) of kidneys. Secondary IN is usually complicated by the course of already earlier existing disease of kidneys or such diseases as a multiple myeloma, leukemia, a diabetes mellitus, gout, vascular damages of kidneys, a hypercalcemia, an oxalic nephropathy, etc. (S. O. Androsova, 1983).

The Acute Intersticial Nephrite (AIN) can arise at any age, including at newborns and at elderly persons, however the vast majority of patients is registered at the age of 20-50 years.

Symptoms of Intersticial nephrite:

Character and weight of clinical manifestations of OIN depends on expressiveness of the general intoxication of an organism and on a degree of activity of pathological process in kidneys. The first subjective symptoms of a disease usually appear in 2-3 days from an initiation of treatment antibiotics (most often penicillin or its semi-synthetic analogs) on geowater of an aggravation of an adenoid disease, quinsy, otitis, antritis, the SARS and other diseases preceding development of OIN. In other cases they arise several days later after purpose of non-steroidal anti-inflammatory drugs, diuretics, tsitostatik, administration of radiopaque substances, serums, vaccines. Most of patients has complaints to the general weakness, perspiration, a headache, pains of the aching character in lumbar area, drowsiness, decrease or loss of appetite, nausea. Quite often mentioned symptoms are followed by a fever with fever, an ache in muscles, sometimes a polyarthralgia, skin allergic rashes. Development of moderately expressed and short arterial hypertension is in some cases possible. Hypostases are not characteristic of OIN and, as a rule, are absent. Also the dysuric phenomena are not observed usually. In most cases from the first days the polyuria with a low relative density of urine is noted (hyposthenuria). Only at very heavy current of OIN at the beginning of a disease considerable reduction (oliguria) of urine up to development of the anury (which is combined, however, with a hyposthenuria) is observed and other signs of OPN. At the same time also the uric syndrome comes to light: insignificant (0,033-0,33 g/l) or (more rare) moderately expressed (from 1,0 to 3,0 g/l) a proteinuria, a microhematuria, a small or moderate leukocyturia, a cylindruria with dominance hyaline, and at a heavy current - and emergence of granular and wax-like cylinders. Often the oksalaturiya and a kaltsiyuriya are found.

The origin of a proteinuria is connected first of all with decrease in a reabsorption of protein an epithelium of proximal departments of tubules, however the possibility of secretion of special (specific) fabric protein of Tamm-Horsfall in a gleam of tubules is not excluded (B. I. Shulutko, 1983).

The origins of a microhematuria are not absolutely clear.

Pathological changes in urine remain throughout all disease (within 2-4-8 weeks). It is especially long (up to 2-3 months and more) the polyuria and a hyposthenuria keep. The oliguria which is observed sometimes in the first days of a disease is connected with increase in intra canalicular and vnutrikapsulyarny pressure that leads to falling of effective filtrational pressure and passing reduction in the rate of glomerular filtering. Along with decrease in concentration ability early (also in the first days) disturbance of azotovydelitelny function of kidneys develops (especially in hard cases) that is shown by a hyperazotemia, i.e. increase in level in blood of urea and creatinine. It is characteristic that the hyperazotemia develops against the background of a polyuria and a hyposthenuria. Perhaps also disorder of electrolytic balance (a hypopotassemia, a hyponatremia, a hypochloraemia) and acid-base equilibrium with the acidosis phenomena. Expressiveness of the mentioned disturbances of kidneys on regulation of nitrogenous balance, acid-base equilibrium and water and electrolytic homeostasis depends on weight of pathological process in kidneys and reaches the greatest degree in case of development of OPN.

As a result of inflammatory process in kidneys and the general intoxication characteristic changes from peripheral blood are observed: the small or moderately expressed leukocytosis with insignificant shift to the left, it is frequent - an eosinophilia, increase in SOE. In hard cases development of anemia is possible. At a biochemical blood analysis S-reactive protein, the raised indicators of DFA-test, sialic acids, fibrinogen (or fibrin), a disproteinemia with giper-a1-and an a2-globulinemiya are found.

At assessment of clinical picture OIN and its diagnosis it is important to mean that practically honor in all cases and in the first days from the beginning of a disease symptoms of a renal failure of various degree of manifestation develop: from slight increase in blood of level of urea and creatinine (in mild cases) to typical picture OPN (at a heavy current). At the same time it is characteristic that development of the anury (expressed to an oliguria) is possible, but it is not obligatory at all. More often the renal failure develops against the background of a polyuria and a hyposthenuria.

In most cases the phenomena of a renal failure have reversible character and pass through 2-3 weeks, however disturbance of concentration function of kidneys remains as it was already noted, for 2-3 months and more (sometimes about one year).

Taking into account features of a clinical picture of a disease and its current allocate (B. I. Shulutko, 1981) the following options (forms) of OIN.

1. The developed form of which all listed above clinical symptoms and laboratory symptoms of this disease are characteristic.

2. OIN option proceeding as "banal" (usual) OPN with a long anury and the accruing hyperazotemia, with staging of development of pathological process, characteristic of OPN, and its very heavy current demanding at assistance to the patient of use of an acute hemodialysis.

3. An "abortal" form with lack of a phase of an anury, characteristic of it, a polyuria prematurity, an insignificant and short hyperazotemia, a favorable current and bystry recovery azotovydelitelny and concentration (within 1-1,5 months) functions of kidneys.

4. A "focal" form at which clinical symptoms of OIN are expressed poorly, erased changes in urine are minimum and changeable, the hyperazotemia or is absent, or insignificant and quickly passing. Recovery of concentration function of kidneys and disappearance of pathological changes in urine are more characteristic of this form sharply arising polyuria with a hyposthenuria, bystry (within a month). It is the easiest on a current and OIN option, optimum on an outcome. It usually passes in polyclinic conditions as "an infectious and toxic kidney".

At OIN forecast most often favorable. Usually disappearance of the main to clinic - laboratory symptoms of a disease comes in the first 2-4 weeks from its beginning. During this period indicators of urine and peripheral blood are normalized, the normal level of urea and creatinine in blood is recovered, the polyuria with a hyposthenuria remains much longer (sometimes up to 2-3 months and more). Only in rare instances at very heavy current of OIN with the expressed phenomena of OPN the failure is possible. OIN can sometimes get a chronic current, mainly at its late diagnosis and the wrong treatment, non-compliance with medical recommendations by patients.

Reasons of Intersticial nephrite:

The reasons causing OIN can be various, but its emergence is more often connect with reception of medicines, especially antibiotics (penicillin and its semi-synthetic analogs, aminoglycosides, cephalosporins, rifampicin, etc.). Streptocides, non-steroidal anti-inflammatory drugs (indometacin, a metindol, Brufenum, etc.), analgetics, immunodepressants (Azathioprinum, an imuran, cyclophosphamide), diuretic, barbiturates, captopril, Allopyrinolum are quite often etiological factors of OIN. Cases of development of OIN as a result of reception of Cimetidinum, after administration of radiopaque substances are described. It can be a consequence of the increased individual sensitivity of an organism to various chemicals, intoxication ethylene glycol, ethanol (I. R. Lazovsky, 1974; B. I. Shulutko, T. G. Ivanov, 1978).

OIN arising under the influence of the mentioned medicinal, chemical and toxic substances and also at administration of serums, vaccines and other proteinaceous drugs, is designated as toksikoallergichesky option of this disease. OIN cases from heavy OPN developing sometimes at patients after viral and bacterial infections designate as postinfectious IN though here it is not always possible to exclude also influence of antibiotics. In some cases the reason of OIN does not manage to be established, and then speak about idiopathic OIN.

Treatment of Intersticial nephrite:

Sick OIN have to be hospitalized in a hospital, at a possibility of a nephrological profile. As in most cases a disease it proceeds favorably, without heavy clinical manifestations, special treatment is not required. Cancellation of that medicine which caused development of OIN has crucial importance. Symptomatic therapy, a diet with restriction of products, protein-rich animal origin, generally meat is for the rest carried out. And extent of such restriction depends on expressiveness of a hyperazotemia: than it is higher, daily consumption of protein has to be that less. At the same time essential restriction of table salt and liquid is not required as liquid delays in an organism and hypostases at OIN are not observed. On the contrary, in connection with a polyuria and intoxication of an organism additional administration of liquid in the form of the vitaminized drinks (fruit drinks, kissels, compotes etc.) is recommended, and also intravenous administration of solutions of glucose, a reopoliglyukin and other disintoxication means is frequent. If OIN proceeds more hard and is followed by an oliguria, appoint diuretics (lasixum, furosemide, Uregitum, hypothiazid, etc.) in individually picked up doses (depending on expressiveness and duration of an oliguria). Antihypertensives are appointed seldom as arterial hypertension is observed not always and if happens, then moderately expressed and has passing character. At a long polyuria and possible disturbance of electrolytic balance (a hypopotassemia, a hypochloraemia and a hyponatremia) carry out correction under control of content of these electrolytes in blood and their daily excretion with urine. If necessary it is necessary to combat acidosis.

In general it is reasonable to avoid whenever possible prescription of medicines, especially at the favorable course of a disease and lack for this purpose of absolute indications. It is desirable to be limited to the desensibilizing means in the form of antihistaminic drugs (tavegil, Diazolinum, Dimedrol, etc.), drugs of calcium, ascorbic acid. In more hard cases inclusion in a complex of medical actions of glucocorticosteroids - Prednisolonum on 30-60 mg a day (or Methypredum in the corresponding doses) for 2-4 weeks, i.e. before disappearance or essential reduction of clinical and laboratory manifestations of OIN is shown. In case of development of a heavy acute renal failure there is a need of use of an acute hemodialysis.