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UDC 616.61-002.3:615.838.7
COMBINATION TREATMENT OF PATIENTS WITH CHRONIC PYELONEPHRITIS BY MEANS OF PELOTHERAPY
Altai State medical University, Barnaul A.I. Neimark, A.V. Davydov
There were studied the possibilities of pelotherapy implementation in the combination treatment of patients with chronic pyelonephritis. It is shown, that the use of sulfide silt muds of Lake Mormyshanskoye has a positive effect on the course of latent inflammation stage of chronic pyelonephritis, allows to reduce clinical manifestations of the diseases, increases the percent of sterile urine culture, improves microcirculation in kidneys, the immune status of patients, cytokine profile of urine and blood serum, provides long-term anti-relapsing effect in 84% of patients.
Key words: chronic pyelonephritis, pelotherapy, combination treatment, sulfide silt muds, Bekhtemirskaya curative clay.
Kidney and urinary tract infection - is a numerous group within the structure of urological pathology ranking second among all human infectious diseases [1].
Chronic pyelonephritis is one of the most common infectious diseases of the urinary system [2, 3]. The most important task of modern urology is the elaboration and implementation of new more effective methods of treatment of chronic pyelonephritis [4].
It is known, that modern restorative treatment at the stage chronic pyelonephritis latent inflammation is able to terminate the pathological process, to postpone relapse for a long period of time and to achieve sustained remission. In order to reach a persistent therapeutic effect patients with chronic pyelonephritis for a long time have to take medications often causing allergic reactions and multiple organ failures [5, 6].
Natural therapeutic factors, as a possible reserve, are an important for the increase of chronic pyelonephritis treatment effectiveness [7]. The ability of pelotherapy to cause changes in many systems of the organism, influence the main elements of pathogenesis of the majority of diseases has been attracting clinical specialists' attention for a long time. At the present time, there are appearing scientific works proving the positive effect of pelotherapy on the course of chronic pyelonephritis [8]. However, the possibilities of pelotherapy to change the microcirculation of kidneys, humoral component of immune system, cytokine hemostasis and bacterial load of urine of patients with chronic pyelonephritis are still insufficiently studied.
Objective: to improve the effectiveness of treatment of patients with primary chronic pyelonephritis at the latent disease stage by means of including pelotherapy in the combination treatment.
Materials and methods
The current research included 73 female pa-
tients from 20 to 65 years old with chronic primary pyelonephritis at the stage of latent inflammation. The average age constituted 45,20+4,5 years. The average disease duration - 8,24±0,79 years, he duration of disease at the moment of appeal ranged from 3 to 18 years. The disease recurrence occurred in patients averagely 3,6 ± 0,2 times during 1 year.
The criteria of patient inclusion: primary chronic pyelonephritis (absence of developmental anomaly of the urinary system and disorders of urody-namics) at the stage of latent inflammation (mild or absent symptoms, minor laboratory manifestations, obligatory leukocyturia, bacteriuria), patients' consent to take part in the study.
The criteria of patient exclusion: chronic pyelonephritis at the stage of active inflammation or remission, presence of symptoms of intermittent or end stage renal disease, hydronephrosis, pyo-nephrosis; tuberculosis of the urogenital system; malignant and benign tumors of the urogenital system, all urological diseases at the acute stage; inflammatory diseases of the genital system, presence of other somatic and systemic diseases at the decompensation stage.
All patients were randomized by means of typological selection into 3 groups comparable by the main parameters - age, disease duration, clinical manifestations and presence of deviations in the urine analysis. The control group consisted of 22 healthy persons at the age from 20 to 65 years.
The patients of all three groups received medication therapy: antibacterial, spasmolytic, pain medication and phytotherapy. The patients of group 2 received an additional course of pelotherapy by Bekhtemirskaya clay in the kidney projection on the lumbar region. The patients of group 2 received an additional course of pelotherapy by curative sulfide silt muds of Lake Mormyshanskoye.
Before the treatment and on the 21th day of treatment all patients underwent a series of diagnostic measures, including the collection of clinical anam-nestic data, general clinical laboratory examination,
ultrasound investigation of kidneys, determination of kidney microcirculation by means of LDF.
The method of clay and mud treatment was similar: peloid was heated on the water bath up to 40-45 0C. The patient was laid onto the therapy bed in the prone position. The 2 sm thick peloid was applied by means of traditional local application in the kidney projection on both sides, then the lumbar region was subsequently covered by the pack sheet, rubber sheet and blanket. Treatment time - 20 minutes. After the procedure the patient was washed by the shower of t -36 0C, rested for 30-40 minutes. The treatment course - 10 procedures, performed every second day.
The statistical data analysis was performed by means of Statistica v6.0, MS Excel 2007. The normality was estimated by means of the Shapiro-Wilk test. The factual data are presented in the form of "mean ± error of mean" (M±m). The comparison of independent samples was carried by means of Mann-Whitney U test, the comparison of samples before and after the treatment - be means of Wilcoxon test. The critical significance level by testing statistical hypothesis was taken to be equal to 0,05. In case of comparison of qualitative parameters in the linked samples there was used Cochran's Q test.
Results and discussion
The evaluation criteria of the effectiveness of treatment of the patients of all 3 groups were: clinical course of the disease, dynamics of laboratory parameters and evaluation of the functional state of kidneys. Thus, for all stated patients along with the basic laboratory blood and urine tests there was conducted the bacteriological urine analysis, was determined the concentration of G, a, M immunoglobulin, anti-inflammatory cytokines IL-1p, TNF-a, IL-6 in blood serum and IL-8 in urine. To evaluate the functional state of kidneys there was performed a radiologic examination and there was indirectly stated the microcirculation of kidneys by means laser Doppler flowmetry.
According to the analysis of the results obtained by the examination of patients, there were determined the changes in the clinical blood analysis - the decrease of hemoglobin level, acceleration of erythrocyte sedimentation rate. The common urine analysis of 100% of patients showed a significant leukocyturia. Nechiporenko's test showed the increase of active and inactive leukocytes.
The bacteriological urine examination of the patients of all groups revealed a particular uro-strain, no sterile culture revealed. There was marked the prevalence of gram-negative microflora. In patients with primary chronic pyelonephritis there were registered Escherichia coli (47,94%), entero-coccus (13,69%), staphylococcus (l0,95%), Klebsiella (6,84%), Enterobacter (6,84%), Proteus (4,10%), 48
microbial associations of Escherichia coli with staphylococcus, enterococcus (9,64%).
By estimation of the humoral component of immune system initially before the treatment in patients with primary chronic pyelonephritis there was registered overproduction of IgG, IgM and reduction of IgA concentration in blood serum, which is considered ad the imbalance of the humoral component of immune system, disorder of anti-infective resistance. The literature contains various data on the content of different classes of Ig by chronic pyelonephritis, but the most often case is the growth of IgG and IgM levels [9, 10].
The study of the cytokine profile of the patients showed a statistically significant increase of activity of anti-inflammatory cytokines (IL-1p, TNF-a, IL-6) in blood serum and cytokine IL-8 in urine samples. As the ejection of IL-8 into urine is one of the activators of continuation of tubolo-inter-stitial inflammation in the urinary system, while the increase of IL-6 concentration in blood leads to the further sclerosis and cicatrization of kidney tissues, we can indicate the continuing inflammatory process in the urinary system [11].
Before the treatment in all three groups the disorder of microcirculation was characterized by the reduction of the microcirculation effectiveness index, index of shunting and myogenic tonus. All these changes indicate the reduction of blood perfusion intensity in the kidneys, ischemia, venous stasis on the background of inflammation in the renal parenchyma and congestive form of microcirculation disorder [12].
The most significant clinical effect was reached in group 3, as the clinical symptoms of chronic pyelonephritis were preserved only in 12% of patients, while in patients of group 1 and 2 - in 47,83% and 28% respectively.
The highest urine sanitation occurred in group 3, thus, by the analysis of bacteriological urine samples, exactly in group 3 there was observed the biggest number of sterile cultures in 88% of cases, in group1 - 52,17%, in group 2 - 68%.
An expressed bacteriostatic effect of mud therapy should also be mentioned, as the degree of bac-teriuria in positive urine cultures reduced: Escherichia coli - from 105-107 CFU/ml to102-103 CFU/ml, Staphylococcus epidermidis - from 105-106 CFU/ml go 102-103 CFU/ml.
By the evaluation of microcirculation the maximum effect was obtained in group 3, which was expressed in the boost of blood flow, increase of perfusion, reduction of kidney tissue hypoxia. Such kind of therapy can restore the blood flow, eliminate ischemia of renal parenchyma and considerably improve the results of chronic pyelonephritis treatment.
The comparative evaluation of the study results allowed to state, that in group 3 after the treatment there was registered a lower level of IgG and IgM
in blood serum, lower levels of IL-1p, TNF-a, IL-6 in blood serum and IL-8 in urine, consequently, a more expressed anti-inflammatory and immune-modulating activity.
The follow-up study of patients showed, that the duration of full clinical laboratory remission in patients with chronic pyelonephritis exposed to the course of combination treatment by curative silt sulfide mud of Lake Mormyshanskoye in 84% of cases constitutes more than 1 year, in groups 1 and 2 - 52,17% and 56% respectively. The disease recurrence in group 3 was registered 3 times rarer in comparison with the patients of group 1 receiving the course of standard medication therapy, and patients of group 2 receiving combination therapy by means of Bekhtemirskaya curative clay.
The obtained results are determined by the effects of curative mud: antiinflammatory, immune-modulating, defibrosing, bactericidal and reparative-regenerative.
During the mud therapy procedure in the zone of mud application there occurs a long-term local skin hyperemia. Local hyperemia leads to the dis-tention of vessels of the microcirculatory bloodstream and speeding of blood flow and lymph efflux of skin. Moreover, the activation of nonfunc-tioning capillaries and arterial venous anastomosis, increase of vascular permeability occur under the influence of biologically active substances effused by skin (histamine, bradykinin). The boost of blood flow in combination with the increase of vascular permeability and pH shifts contributes to the improvement of transportation of chemical substance dissolved in the mud, interstitial fluid outflow and oxygen flow to the cells [13].
Thus, the suggested curative complex including mud therapy proved its high effectiveness and rea-sonability of implementation in patients with primary chronic pyelonephritis at the stage of latent inflammation in order to prevent the progression of disease, prolongation of remission terms and to improve the life quality of patients.
The volatile substances, ions, lipoidotropic pep-tide and steroid hormone substances, humic acids and non-polar gas molecule (chemical factor) contained in the mud penetrate into the skin through the channels of sebacerous glands and hair follicles. Biologically active substances accumulated in skin improve the metabolism of subjacent tissues, increase excitability and conduction of skin nerve guides. Anti-inflammatory activity of curative muds manifests itself at the exudative and pro-liferative inflammation stages.
Humic acids and steroid containing peloid fractions having penetrated through epidermis at the exudative inflammation stage limit exudation and edema of tissues. In the area of inflammation they restrain the migration of leucocytes and edema due to the oppression of hyaluroni-dase destructive function. Increasing the activi-
ty of the components of the antioxidant system, they suppress peroxidation of lipids in the area of inflammation. Chemical components of curative mud suppress the polymerization of collagen fibres and boost the aggregation of glycosaminogly-cans, mucoproteins and glycoproteids. As a result, the collagen producing function of fibroblasts decreases, which leads to the fibrosis slowdown [13].
Conclusion
Consequently, the implementation of pelother-apy in combination treatment of patients with chronic pyelonephritis positively effects the course of latent inflammation stage, allows to reach the reduction of clinical manifestations of the disease, increases the percent of sterile urine cultures, improves the kidney microcirculation, immune status of patients, cytokine profile of urine and blood serum and, thus, contributes to the prolongation of full clinical laboratory remission by more than 1 year in 84% of patients.
References
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Contacts:
Corresponding author - Neimark Aleksandr Izrai-levich, Doctor of Medical Sciences, Professor, Head of the Department of specialized surgery in urology, traumatology and ophtalmology of the FSBEI HE Altai State Medical University of the Ministry of Health of the Russian Federation, Barnaul. 656050, Barnaul, Malakhova Ulitsa, 51. Tel.: (3852) 404741. Email: urologagmu@mail.ru
