acute pyelonephritis


Introduction to acute pyelonephritis Acute pyelonephritis (acutepyelonephritis) is an acute suppurative inflammation caused by bacteria invading the renal pelvis, renal pelvis and renal parenchyma. The course of the disease is no more than 6 months. There are two ways of infection: 1 ascending infection, the bacteria enter the renal pelvis from the ureter, and then invade the renal parenchyma. 70% of acute pyelonephritis is derived from this pathway. 2 bloody infection, bacteria from the blood into the renal tubules, from the renal tubules into the renal pelvis, accounting for about 30%, mostly staphylococcal infection, urinary tract obstruction and urinary stagnation is the most common cause of acute pyelonephritis, simple pyelonephritis rarely seen. basic knowledge The proportion of illness: 0.005%-0.009% Susceptible people: no specific population Mode of infection: non-infectious Complications: urinary tract obstruction bacteremia shock pyelonephritis


Causes of acute pyelonephritis

(1) Causes of the disease

The bacteria infected with pyelonephritis mainly come from the urinary tract infection. When using various instruments or transurethral surgery, the bacteria can be brought in by the body and infected through the urethra, but more commonly the intestinal bacteria that migrate to the perineum pass the urethra. , bladder, ureter to kidney, urinary tract obstruction and urinary stagnation are the most common causes of acute pyelonephritis. The urinary tract is dilated and effusion above the obstruction, which is conducive to bacterial reproduction, causing pyelonephritis, pyelonephritis often by Gram Caused by negative bacilli, accounting for more than 70%, of which Escherichia coli is the most common, followed by Proteus, Klebsiella, Aerogen, Pseudomonas aeruginosa, etc.; Gram-positive bacteria account for about 20%, common For Streptococcus and Staphylococcus, recent studies have found that some Escherichia coli strains have P-pilus on the surface, and their adhesin binds to the urothelial-specific P. faecalis receptor, which adheres to the urothelium and causes acute Pyelonephritis, P-pillar adhesins are classified into grade I, grade II, and grade III. Among them, strains with grade II adhesin are closely related to pyelonephritis, and blood is sexy. Only about 30% of the infection, mostly staphylococcal infection.

(two) pathogenesis

Urinary tract infection is caused by the invasion of pathogenic bacteria, and its pathogenesis is related to pathogen infection. The ways and ways of pathogen invasion and infection are roughly divided into the following.

1. Upstream infection is about 95% of urinary tract infections. The pathogen is from the urethra to the kidney through the bladder and ureter. Under normal circumstances, a small amount of bacteria is present at the upper end of the urethral orifice 1 to 2 cm, only when the body's resistance is reduced. Or when the urethral mucosa is damaged, bacteria can invade, multiply, wash urine, IgA in urine, lysozyme, organic acid, mucosal integrity, and mucosin secreted by bladder transitional epithelium can resist pathogenic bacteria. Invasion, in recent years, electron microscopy confirmed that there are many P-pilus on the surface of Escherichia coli, which can specifically recognize and bind to the corresponding receptors on the surface of urothelial cells, so that the bacteria adhere closely to the urothelial cells. Avoid being washed away by urine. Escherichia coli has bacterial (O) antigen, flagellar (H) antigen, capsular (K) antigen, polysaccharide K antigen can inhibit phagocytic bactericidal activity, and its pathogenicity is direct Related, Proteus has no P and K antigens, and is not easy to adhere to the transitional epithelium of the bladder, but can adhere to the squamous epithelial cells of the external genitalia, indwelling catheter, urinary calculi, trauma, tumor, Prostatic hypertrophy, congenital urinary tract abnormalities (including ureter bladder wall, due to vesicoureteral reflux sphincter hypoplasia), and so is neuron bladder infection risk factor for the uplink.

2. Hematogenous infections only account for less than 3% of urinary tract infections. The blood flow of the kidneys accounts for 20% to 25% of the stroke volume. In sepsis and bacteremia, bacteria in the circulating blood easily reach the renal cortex. , diabetes, polycystic kidney disease, transplanted kidney, urinary tract obstruction, renal vascular stenosis, analgesic or sulfa drugs increase the vulnerability of kidney tissue, common pathogens are Staphylococcus aureus, Salmonella, fake Monocytogenes and Candida albicans.

3. The chance of direct infection is rare, and lymphatic infection has not been confirmed.

(1) urinary tract obstruction: urinary tract obstruction caused by various reasons, such as kidney and ureteral calculi, urethral stricture, urinary tract tumor, prostatic hypertrophy, etc. can cause urine retention, making bacteria easy to breed and produce infection, pregnancy uterus compression The ureter, renal ptosis or hydronephrosis can cause poor urine excretion and cause the disease.

(2) urinary system malformations or dysfunction: such as renal hypoplasia, polycystic kidney disease, sponge kidney, hoof iron kidney, double renal pelvis or double ureteral malformation and huge ureter, etc., are easy to reduce the resistance of local tissue to bacteria, bladder ureter Reflux causes urine to flow back from the bladder to the renal pelvis, thus increasing the chance of illness, urinary dysfunction of the neuronal bladder, leading to urinary retention and bacterial infection.

(3) urethral intubation and device examination: catheterization, cystoscopy, urinary tract surgery can cause local mucosal injury, the pathogen of the anterior urethra into the bladder or upper urinary tract infection, according to statistics, a guide The incidence of persistent bacteriuria after urine is 1% to 2%; the indwelling catheterization for more than 4 days, the incidence of persistent bacteriuria is more than 90%, and there is a risk of severe pyelonephritis and gram-negative septicemia.

(4) Female urinary tract anatomy and physiology characteristics: female urethra length is only 3 ~ 5cm, straight and wide, urethral sphincter is weak, bacteria easily rise to the bladder along the urethra, and the urethral orifice is close to the anus, providing conditions for bacteria to invade the urethra, urethra Local irritation around, menstrual period genital area susceptible to bacterial contamination, vaginitis, cervicitis and other gynecological diseases, pregnancy, postpartum and sexual life changes in sex hormones, can cause vaginal, urethral mucosal changes and facilitate the invasion of pathogenic bacteria, Therefore, the incidence of urinary tract infection in adult women is 8 to 10 times higher than that in men.

(5) weakened body resistance: systemic diseases such as diabetes, high blood pressure, chronic kidney disease, chronic diarrhea, long-term use of adrenal cortex hormones, etc., the body's resistance decreased, the incidence of urinary tract infections increased significantly.

4. Virulence factors of bacteria Urinary tract infections are caused by a single strain, such as Escherichia coli, which accounts for the majority of urinary tract infections, can cause from asymptomatic bacteriuria to cystitis and all pyelonephritis. Escherichia coli that invades the urinary tract is not only the most popular flora in the feces, but they also have some special strains that have various virulence characteristics that can travel through the intestines and continue in the vagina. Then, ascending to the anatomy of the normal urinary tract, when there is foreign body in the urinary tract, VUR or obstruction, it is more prone to ascending infection.

The antigen of Escherichia coli is O antigen (hapten or cell surface antigen), H antigen (flagellate antigen) and K antigen (membrane antigen), the serological type associated with asymptomatic bacteriuria and the strain from symptomatic patients are obvious Differently, in this way, 8 of the approximately 170 different O antigens (O1, O2, O4, O5, O7, O16, O18 and O75) Escherichia coli strains account for 80% of pyelonephritis caused by this species. In addition, a small amount of K antigen (K1, K2, K5, K12 and K13 or K51) is isolated in more than 70% of pyelonephritis pathogens. On the contrary, H antigen does not seem to be related to virulence alone, and may not be Escherichia coli. The O antigen itself causes the urinary tract pathogenicity of these Escherichia coli strains. Specifically, the genes that determine the structure of the O antigen and the genes closely associated with them are closely related to the pathogenicity of these bacterial strains.

In short, the mechanism of urinary tract infection is a rather complicated process, which can be summarized as follows:

(1) Bacterial colonies with P hairs are scattered around the intestines and urethra and spread to the urethra.

(2) Through the turbulent flow of urine in the ureter, the bacteria ascend to the kidney. If the inflammation is not controlled in time, the kidney tissue is damaged and fibrosis eventually occurs.

(3) Through urine reflux, the bacteria are retrograde in the urinary tract and bind to the corresponding receptors of the epithelial cells of the urinary tract. Local reproduction causes inflammation of the kidney, and the infected kidney can stimulate the autoimmune response of the anti-renal tissue antigen, resulting in There is no persistence of kidney damage in the absence of continuous bacterial growth.

In the case of acute pyelonephritis, tubular damage can release tubule antigen into the blood circulation, inducing antibody-mediated tubulointerstitial disease, but several studies have not yet demonstrated the presence of anti-renal antibodies in the serum of patients or animals with bacterial pyelonephritis or in experiments In pyelonephritis, there are locally synthesized IgG and IgM, and in animal or human pyelonephritis, both granulocyte-free IgG and complement (indicating immune complex type tubular disease) and wireless deposition are observed by immunofluorescence microscopy ( It suggests that the anti-tubular basement membrane disease), however, Losse found in the experimental rabbit pyelonephritis antibodies directly against the E. coli antigen, this antibody can also react with antigens from liver and kidney tissues, and antibody to pyelonephritis A controversial topic in terms of autoimmune response is that pyelonephritis is confined to one side of the kidney and often causes complete obstruction, while the contralateral kidney is normal, which occurs in patients with unilateral obstruction, and experimental animals have repeatedly demonstrated this. point.

5. Pathological changes

The pathogenic bacteria have a special bacterial clone from the lower urinary tract to the renal pelvis through the ascending infection pathway, the renal pelvis, the urine collecting system, the renal tubules and the renal parenchyma. The kidney congestion and edema cause the kidney to increase in size, but the lesion is not Homogeneous, leukocyte infiltration in the renal papilla, and quickly spread to the renal cortex, the renal tubule contains a large number of neutrophils, local release of cytotoxin to necrosis of the renal tubular epithelium, with the disease progress, the formation of the kidney Many small abscesses, glomeruli are generally unaffected unless severe necrosis or a kidney infection occurs.


Acute pyelonephritis prevention

Pyelonephritis is mainly caused by the invasion of pathogenic bacteria into the ascending infection. The main measure is to prevent pathogenic bacteria from infecting the urinary tract. The specific methods are as follows:

1. Insist on drinking more water every day, urinating frequently to flush the bladder and urethra, and avoid bacteria in the urinary tract. This is the easiest and most effective measure.

2. Pay attention to the cleansing of the genitals to reduce the bacterial flora in the urethra. If necessary, apply neomycin or furanodine cream to the mucosa or perineal skin of the urethra to reduce the on-site re-infection.

3. Try to avoid using urinary tract equipment and strictly aseptically operate if necessary.

4. Repeated episodes of pyelonephritis should be given a dose of antibacterial drug every night. You can choose one of the drugs such as sulfamethoxazole, furazolidin, amoxicillin or cefradine. If there is no adverse reaction, Can be used for more than 1 year, such as the onset of illness and sexual intercourse, should immediately urinate after sex, and take a dose of antibiotics, can also reduce the recurrence of pyelonephritis.


Acute pyelonephritis complications Complications, urinary tract bacteremia, shock, pyelonephritis

If acute pyelonephritis is diagnosed and treated promptly, complications are rare, and the prognosis of acute pyelonephritis with latent kidney disease or urinary tract malformation is relatively poor, and pathogenic bacteria often have drug resistance, such as not removing kidneys. Stones, especially those with infection, are difficult to control, and infections that are complicated by urinary tract obstruction are difficult to cure. They often evolve into chronic processes and can cause bacteremia.

The most serious complication of acute pyelonephritis is toxic shock. Gas-producing pyelonephritis is a rare but fatal pyelonephritis, usually seen in diabetic patients, caused by pathogenic bacteria (usually a strain of Escherichia coli) Release gas into infected tissue.

After adequate treatment, there is no other kidney disease or urinary tract malformation. Acute pyelonephritis usually heals without causing kidney scar or persistent kidney damage. On the contrary, infants and young children whose kidneys are not fully mature, especially in the kidneys Acute pyelonephritis of disease or urinary tract malformation often causes persistent damage to the kidneys and scars.


Acute pyelonephritis symptoms Common symptoms True bacteria urinary tubule interstitial nephritis Upright urinary proteinuria pain Abdominal pain Nocturia increased fever with frequent urination, urine... High level of urinary urinary serum... Renal artery thinning or obstruction

Typical acute pyelonephritis has a rapid onset, clinical manifestations of paroxysmal chills, fever, low back pain (significant slap pain at the rib angle), usually accompanied by abdominal cramps, nausea, vomiting, dysuria, Frequent urination and nocturia, the disease can occur in all ages, but the most common in women of childbearing age, mainly have the following symptoms.

1. General symptoms of high fever, chills, body temperature is more than 38 ~ 39 ° C, can also be as high as 40 ° C, heat type is different, generally relaxation type, can also be intermittent or missed type, with headache, body aches, hot retreat There may be sweating and so on.

2. Patients with urinary symptoms have low back pain, mostly dull or sore, varying degrees, a few have abdominal cramps, radiating along the ureter to the bladder; physical examination at the upper ureteral point (the intersection of the rectus abdominis and the umbilical line) ) or the waist point (the outer edge of the psoas muscle and the intersection of the twelve ribs) has tenderness, and the kidney area is positive for pain. The patient often has frequent urination, urgency, dysuria and other bladder irritation. In the case of ascending infection, Appears in systemic symptoms.

3. Gastrointestinal symptoms may have loss of appetite, nausea, vomiting, and individual patients may have pain in the upper abdomen or total abdomen.

4. Bacteremia and sepsis Although patients with symptomatic acute pyelonephritis may have bacteremia during their disease, this bacteremia and more severe Gram-negative sepsis ( That is, there is no significant correlation between septic shock caused by activation of complement, coagulation and kinin systems, DIC or both.

5. Shock and DIC When pyelonephritis occurs in shock or DIC, the possibility of urinary tract obstruction must be ruled out. One of the most important cases is obstructive nephropathy associated with acute renal papillary necrosis, which can cause ureter due to detachment of the renal papilla. Obstruction, if diabetic patients with severe pyelonephritis or bacteremia, especially when patients have poor response to treatment, should be highly suspected of the possibility of renal nipple necrosis.

6. Children's patients with urinary symptoms are often not obvious, in addition to high fever and other systemic symptoms, often convulsions, convulsions, children under 2 years of age, such as fever, vomiting, non-specific abdominal discomfort or not moving It may be acute pyelonephritis; the only meaningful evidence may be that it is not moving, UTI accounts for about 10% of its febrile diseases; for older children, its clinical manifestations are similar to those of adults. When children have recurrent enuresis At the time, it often prompts a decrease in the concentration function of urine associated with intrarenal infection.


Examination of acute pyelonephritis

Laboratory inspection

Urine routine examination

(1) Visual observation: urine color can be clear or turbid when pyelonephritis, can have a stinky smell, and very few patients present with gross hematuria.

(2) microscopic examination: 40% to 60% of patients have microscopic hematuria, most patients have red blood cells 2 to 10 / HPF, a small number of red blood cells under the microscope, common white blood cell urine (ie pyuria), urine sediment after centrifugation > 5 / HPF, the acute phase often shows white blood cells full field of view, if you see the white blood cell cast type, it provides an important basis for the diagnosis of pyelonephritis. At present, the domestic useful blood cell count disk check clean and not centrifuge urine, to 8 / Mm3 is pyuria, the following points should be noted when making this test:

1 The vulva must be cleaned before leaving the urine. Otherwise, false positives may occur due to contamination. When taking urine, women should be careful not to mix in vaginal discharge.

2 If the urine is left for several hours, the destruction of white blood cells will make the results inaccurate.

3 pyuria can be intermittent, should be repeated many times to draw conclusions.

4 After antibacterial treatment, although there is pyuria in the short term after treatment, it can affect the accuracy of the results.

5 Proteus, Pseudomonas aeruginosa, pyelonephritis caused by Klebsiella, because the urine is alkaline, the white blood cells in the urine are destroyed, and false negative results may occur.

The leukocyte esterase test strip confirms a sensitive and rapid screening test for leukocyteuria with a sensitivity of 87% and a specificity of 94.3%. In recent years, it has been examined for urinary lactoferrin (LF) in leukocytes. As a marker of leukocyteuria, the lactoferrin metabolite can be detected by ELISA for 10 minutes. The sensitivity of leukocyte urine is 95.0% and the specificity is 92.9%. It is rapid and simple as a screening method.

(3) urinary protein content: urinary protein qualitative examination of pyelonephritis is trace ~ +, quantitative examination 1.0g / 24h or so, generally not more than 2.0g / 24h.

2. Quantitative culture of urinary bacteria Quantitative culture of urinary bacteria is an important indicator for determining the presence or absence of urinary tract infection. As long as the conditions permit, the middle urinary tract should be used for quantitative culture of bacteria. To ensure the correctness of the culture results, attention should be paid to the specimens: 1 Before the application of antibacterial drugs or after the antibiotics are stopped for 5 days, the specimens are taken; 2, in order to keep the urine in the bladder for 6-8 hours, there is sufficient breeding time, and the first urine in the morning should be taken as a specimen; When the urine is strictly aseptic, first clean the vulva, foreskin, disinfect the urethral opening, and then take the middle urine, and do the bacteria culture within 1h, or refrigerate storage. The quantitative culture method of urine bacteria is as follows:

(1) Simple Dilution Dish Method: In the past, the quantitative culture of urinary bacteria was carried out by standard or diluted dumping. In recent years, Zhongshan Medical University used the simple dilution dumping method for quantitative bacterial culture, using 0.1 ml of diluted urine 100 ml. The dishing method is used for colony counting after 24 hours of culture, and >100 is 100,000/ml. After comparison, the result of this method is 100% compared with the standard, so it is considered to be a substitute for standard dumping. law.

(2) Slide culture method: two ordinary slides are used, one end of which is coated with a layer of ordinary agar medium, and one piece is coated with eosin-methylene medium (EMB) which can inhibit the growth of Gram-positive cocci. Inoculation, the slide end coated with the medium is immersed in the fresh cleaned middle urine sample, and then taken out, and the excess urine is dripped and cultured for 24 hours, and the number of colonies is calculated, for example, the number of colonies in the range of 1 cm 2 on the slide is >200. Indicates that the amount of bacteria is >100,000/ml, 30 to 200 are suspicious, and 30 or less are negative. Since the two media are used in this method, it is helpful to distinguish between cocci infection or bacillus infection if two mediums are grown. If the bacteria are the same, it is a bacillus infection; if there is only bacteria on the agar medium, it is a cocci infection; if the number of bacteria dissolved on the two mediums is large, and the colonies of the agar are significantly increased, the size of the colonies is different, then Mostly pollution, this method is simple, saves time and materials, and can be used as a screening test.

(3) Quantitative ring scribing: The method is simple, but due to the cooling and heating of the loop, it is easy to cause deformation, so that the absorbed urine has a 50% difference, so 2% to 10% of false positives can occur.

The diagnostic criteria for true bacterial urine is to use the cleaned mid-stage urinary bacteria to quantify the colony count 100,000/ml for meaningful bacteriuria, and can be diagnosed as urinary tract infection, while the colony count is suspicious from 10,000 to 100,000/ml; <10 10,000 / ml for pollution, the application of this standard, the coincidence rate of urine culture results for asymptomatic urinary tract infections 80% ~ 85%, repeated secondary culture, the diagnostic compliance rate of up to 95%, its specificity of 99% In 1982, Statmm et al. proposed that for women with urinary tract irritation, the number of colonies in the middle-stage urine culture 100/ml can be diagnosed as urinary tract infection, and the possibility of urine pollution in adult males with urinary tract irritation is small. Lipsky In 1989, it was also diagnosed that the colony count of this patient was 1000/ml. Warren (1987) considered that the number of colonization of colonization culture >100/ml was particularly meaningful for bacterial urine. For the sake of caution, it is difficult to determine whether it is meaningful or not. At the time, it is feasible to culture the pubis on the bladder and culture it to bacteria, which is a meaningful bacterial urine.

3. Urine smear microscopy bacterial method:

(1) Non-centrifugal precipitation urinary smear microscopic examination Bacterial method: directly smear fresh mid-stage urine without centrifugation, find bacteria under the microscope, can be checked without staining or Gram stain, the positive rate is 79.6% (check 10 fields of view, more than 1 bacteria are positive).

(2) urinary sediment smear microscopy bacterial method: Gram staining or non-staining inspection, the positive rate is 86.9% and 91.7%, respectively. The urinary smear microscopy bacterial method has the following advantages: 1 device is easy to operate, suitable for Primary medical units or large-scale screening tests, 2 have quantitative significance, experiments prove that, for example, urine bacteria content 100,000 / ml, more than 90% of positive results, very few false positives, 3 antibiotics after application, even if urine culture is negative, mirror The bacteria may still be found in the test.

4. Urine chemical examination This method is simple and easy, but the positive rate is low and the value is limited. It can not replace the quantitative culture of urine bacteria. The main methods are as follows:

(1) Griess test: The principle is that Escherichia coli and E. coli can reduce the nitrate in urine to nitrite, which reacts with the reagent to produce red diazosulfonamide salt. , the results can be observed in a few seconds.

(2) Triphenyltetrazolium chloride test: The principle of triphenyl tetrazolium ehloride (TTC) is that when there is dehydrogenation bacteria in the urine, it is 4 h in a 37 ° C incubator. The TTC reagent can be reduced to a red precipitate (formazon), Escherichia coli, secondary E. coli infection is often positive, staphylococcus, streptococcus, and Pseudomonas aeruginosa are negative.

(3) Other urinary chemical examinations: Landin measured urinary ATP levels in patients with urinary tract infections in 1989. It is believed that ATP>50mmol/L can diagnose urinary tract infections. Nurimnen believes that chromogenic limulus assay causes urinary tracts against Gram-negative bacteria. Infection is a fast and reliable method.

In 1989, Colombrila proposed that the determination of bacterial concentration in urine is a rapid and sensitive screening test for the diagnosis of significant bacteriuria (Bae-Tec-Screen) with a sensitivity of 97.6%, but the specificity is poor. In 1998, Matsutrae et al. -UTIS checks the urine to catch the bacteria through the filter and then carries out three kinds of reagent staining tests. It can accurately judge the positive result of 100,000/ml bacteriuria. The positive coincidence rate is 73.1%, and the negative coincidence rate is 81.1%.

5. Urinary leukocyte excretion rate Urine leukocyte excretion rate is a method for accurately measuring leukocyte urine. In the past, the Addis counting method was required to leave 12 hours of urine. In recent years, 1 hour urine cell counting method was used. Method: Accurately collect all urine of patients for 2 or 3 hours. Liquid, immediately white blood cell count, the resulting white blood cells converted to 1h, normal human white blood cells <200,000 / h, > 300,000 / h is positive, between 200,000 ~ 300,000 / h is suspicious, the positive rate of 88.1%.

6. Blood routine examination of white blood cell count and neutrophils can be increased in the acute phase, chronic red blood cell count and hemoglobin can be slightly reduced.

7. Serological tests are more clinically significant in the following ways:

(1) Immunofluorescence technique to check antibody-encapsulated bacteria (ACB): Under the fluorescence microscope, urinary bacteria treated with fluorescein-labeled anti-human protein are observed. If the surface is coated with antibodies, most of them are pyelonephritis, which is helpful for urinary tract infection. In the diagnosis of location, the positive criteria for ACB vary. Jones believes that at least two cells with high fluorescence are positive in 200 high power fields. Thomas and others believe that at least >25% of bacteria are positive for fluorescence. Brumffit It is believed that one of the 100 bacteria is positive for every 100 bacteria.

(2) Identification of serotypes of urinary bacteria: Identification of serotypes of bacteria in urine helps to distinguish between recurrence and reinfection. If recurrence is the same as the serotype of bacteria cultured in the previous pyelonephritis, it is recurrence. In the past, the use of pulsed field gel electrophoresis (PFGE) technology for bacterial chromosome gene analysis can more accurately determine whether recurrence or reinfection, PFGE The method first mixes the identified bacteria with agar to make an agar block, and after removing the bacterial protein with protease-K and sodium lauryl sarcosinate, the chromosomal DNA in the agar block is digested by the restriction enzyme Not I, and the digested The agar block was placed in a 1% agarose gel and electrophoresed using the CHEF-DRII system to obtain the chromosomal gene pattern of the bacteria to determine its genotype. The results of PFGE method for genotyping bacteria and serological methods were used. Compared with the results of typing, it can be seen that the PFGE method is finer and more precise than the serotyping method. In one serotype, it can be divided into several genotypes. The strains of these different genotypes are serotypes. With its sensitivity to different antibiotics, which can be explained by bacterial serotypes is inconsistent with the kind of sensitivity to antibiotics Why, accordingly, can more precisely use of antibiotics.

(3) Tatom-Horsefall (TH) protein and antibody assay: It has been reported that serum anti-THP antibody titer increases in acute pyelonephritis, urinary THP content decreases in chronic pyelonephritis, and urinary THP-coated free cells are positive in pyelonephritis.

(4) Determination of urinary 2 microglobulin (2-MG): Most scholars believe that in pyelonephritis, the content of urinary 2-MG is increased, and the coincidence rate is up to 82%.

8. Renal function test Acute pyelonephritis occasionally has urinary concentrating dysfunction, which can be recovered after treatment. Chronic pyelonephritis may have persistent renal dysfunction:

(1) Decreased renal concentrating function, such as increased nocturia, and decreased morning urine penetration.

(2) renal acidification decline, such as morning urine pH increase, urine HCO-3 increased, urine NH4 decreased.

(3) glomerular filtration dysfunction, such as decreased endogenous creatinine clearance, blood urea nitrogen, creatinine and so on.

Film degree exam

1. X-ray examination of the abdominal plain film may be due to the abscess of the kidney and the shape of the kidney is unclear. Intravenous urography can be found that the development of renal pelvis is delayed and the development of renal pelvis is weakened. It can show urinary tract obstruction, kidney or ureteral malformation, stones, foreign bodies, tumors. Such as the primary lesion.

2. CT examination of the affected side of the kidney shape enlargement, and visible wedge-shaped strengthening area, from the collection system to the renal capsule radiation, lesions can be single or multiple.

3. B-ultrasound showed that the renal cortex medulla was unclear, and there was a region lower than the normal echo, and it was also confirmed whether there were obstruction or stones.


Diagnosis and diagnosis of acute pyelonephritis


Acute pyelonephritis usually has typical symptoms and abnormal urine findings. It is not difficult to diagnose. If there is only high fever and the urinary tract symptoms are not obvious, it should be differentiated from various febrile diseases. Abdominal pain and low back pain should be associated with cholecystitis and appendicitis. , pelvic inflammatory disease, perirenal abscess and other identification, generally after a number of urination examination can be a clear diagnosis.

Differential diagnosis

1. Febrile diseases When the symptoms of systemic infection of acute pyelonephritis are prominent and the local symptoms of urinary tract are not obvious, it is easy to be confused with febrile diseases such as malaria, typhoid, sepsis, etc. Misdiagnosis accounts for about 40%, but if detailed Asking about the medical history, especially paying attention to the significant chills and snoring of the ribs often indicate the possibility of the disease. It is not difficult to identify through urine sediment and bacteriological examination.

2. Abdominal organ inflammation Some acute pyelonephritis may have no local symptoms of urinary tract, but manifested as abdominal pain, nausea, vomiting, fever, increased white blood cells, etc., easily misdiagnosed as acute gastroenteritis, appendicitis and female attachment inflammation.

3. Identification of a small number of cases with FHCS should be noted with the identification of Fits-Hhagh-Curts syndrome (FHCS), Curts of 1930, first reported by Fits-Hugh in 1934, the patient is characterized by gonococcal salpingitis with perihepatitis, Later, it was found that the same symptoms were found in Chlamydia trachomatis infection. At present, the perihepatitis associated with pelvic inflammatory disease is called FHCS. Women of childbearing age have gynecological symptoms first, then right upper quadrant pain, no liver, gallbladder or pancreas examination. In case of abnormality, the syndrome should be differentiated from right pyelonephritis, and urinary bacteriological examination can help to distinguish the two.

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