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Akhmedzhanova Nargiza, Samarkand State Medical Institute, Ph D., in medicine, department of pediatrics № 3 and medical genetics
E-mail: [email protected]
EFFECT OF COMPLEX TREATMENT ON INDICATORS OF ENDOGENOUS INTOXICATION IN DISMETABOLIC CHRONIC PYELONEPHRITIS IN CHILDREN
Abstract: The aim of this work was an attempt to evaluate the effect of complex treatment on some endogenous intoxication (EI) indicators in chronic pyelonephritis developed on the background of dismetabolic nephropathy (DMN) (DCP). Materials and methods - A survey of 130 children DCP, aged from 4 to 15 years has been carried out. Patients were divided into 3 groups depending on treatment method. Results - comparative assessment of the results of the study of endogenous intoxication conducted after treatment in children with DCP, depending on the method of treatment, demonstrated the effectiveness of "renal tyubazh" compared to other methods of therapy. Conclusion - the use of complex treatment of "renal tyubazh" with DCP is the most appropriate method of therapy. This method leads to the restoration of the TCA (total concentration of albumin) and ECA (effective concentration of albumin) in the blood, TCA and AMP (medium molecular peptides) in the urine.
Keywords: endogenous intoxication, medium molecular peptides, regional lymph antibiotic therapy, kanefron N.
Introduction. Chronic pyelonephritis (CP) in children is characterized by a high tendency to growth and represents a serious medical and social problem, accounting for 40% to 70% in the structure of the urinary system. Often, pyelonephritis become disease in childhood, and suffers from it all subsequent life [1,2]. At present, it has been established that an important component of the pathogenesis of CP is the instability of cytomembranes of the renal epithelium [3, 4, 5]. The prevalence of DMN is from 1 to 32-42 per 1,000 children. The prevalence of oxalate-calcium crystalluria in Uzbekistan is 30-60 per 1,000 children. In addition, the surface of the crystals creates a layer between the microorganisms and the cells of the renal tubules, and the absence of direct contact with bacteria weakens the bactericidal properties of the urothelium. We cannot deny the direct effect of calcium oxalate crystals on the urinary tract epithelium, which induces the development of the inflammatory process, possibly through the amplification of osteopontin by renal cells, which is a known stimulator of the cascade of inflammatory reactions. Among the mechanisms that
cause damage to biological structures of cells in dysmeta-bolic chronic kidney disease DCKD is the activation of the production of toxins of metabolic disorders [6]. EI occurs in chronic inflammatory diseases of the kidneys; their presence in the urine is a qualitative and quantitative criterion of damage to cells of the proximal tubules [7]. An increase in the level of urinary AMP in urine with DCP is associated with the fact that their low molecular weight allows free passage through glomerular capillaries, but in the proximal tubules they are reabsorbed by 99,9%. In the inflammatory-destructive processes of the tubulointerstitial system, the reabsorption ofAMP is disrupted and their excretion in the urine is observed [8, 9]. Despite the use of all new antibacterial agents in pyelonephritis and the development of optimal options, the effectiveness of traditional methods of administration is reduced. It is known that lymphotropic administration gives completely new properties to low-molecular drugs (antibiotics), through which they penetrate through biological barriers and penetrate into scar-altered and inflamed kidney tissue, which allows creating a sufficient
therapeutic concentration there (Shodmonov A. K., 2012) [10, 11].
The aim of the work is to study the effect of complex treatment on EI indices in chronic pyelonephritis in children.
Materials and methods. 130 patients with chronic pyelonephritis were examined at the stage of exacerbation and at discharge from the hospital at the age of 4 to 15 years. Patients were conditionally divided into 3 groups depending on the method of treatment. Group 1 included 48 patients who received conventional therapy (in the first three days, usually cefotaxime i.m, after receiving the results ofbacteriological study - antibacterial drug depending on the sensitivity of the pathogen). Group 2 consisted of 45 patients who received regional lympho-tropic antibiotic therapy (RLAT) in combination with KanefTon H, and the third group consisted of 37 patients who received "renal tuba" (RLAT in combination with water load, Kanefron H and electrophoresis with 0,5% euphyllin). The material for the study of endogenous intoxication was peripheral blood taken from the ulnar vein in patients on the background of exacerbation of the chronic recurrent process and during remission. Determination of the content of medium-molecular peptides in blood serum and in urine was carried out according to the method of I. I. Zhadenova (2002), the total concentration of albumin (TCA) by a unified method for the reaction with bromocresol green (BKZ) using the "albumin-UTS" kits and the effective concentration of albumin (ECA) in the serum by the fluorescent Gryzunov method (1994) on the analyzer AKL-01. The binding capacity of albumin (BCA) was calculated by the formula: BCA = ECA / TCA (%). Mathematical processing of the obtained results was carried out using the parametric t-test of the Student and the non-parametric Mann-Whitney criterion using computer statistical programs. It is generally accepted in cholecystitis that the tubyage proposed in 1948 by G. S. Demyanov (blind probing), on the basis of this term, we propose to call this complex treatment "renal tuba" (patent RU No. 04046 (2009), patent RU No. 20150248 (2017)), since this method promotes the isolation of salts and small concrements from the renal pelvis in the urine. The technique of complex treatment of "renal tuba" was performed. Water is used by using 15 ml / kg of liquid (warm boiled water, unconcentrated tea), then the drug kanefron H is used at a dose of 1-2 tablets 3 times a
day orally and lymphotropic administration of a lympho-stimulant and an antibiotic, after which, 15 minutes electrophoresis with 0,5% solution of euphyllin in warm water on the lumbar region. The causal relationship between the set of essential features of the claimed method and the technical result achieved is as follows. RLAT was carried to the paranephric fiber through the intersection point XII of the rib and the outer edge of the long back muscle (m. sacrospinalis), where the skin was pre-treated with alcohol or iodine. Then, at this place, a thin needle puncture was performed and 0,25% solution of Novocain was administered as a lymphostimulator at the rate: for children with a body weight of up to 16 kg, 3-5 ml and more than 16 kg, 5-10 ml, after 5-10 min antibiotic (cefotaxime) was administered in the amount of1/3 of the daily dose (i.e., from the calculation of 50 mg/kg of body wei ght). We directed the needle perpendicular to the skin surface or with a slight inclination of its acute end to the midline of the body. The depth of needle insertion did not usually exceed 2-3 cm (depending on the age and nutrition of the child). Electrophoresis with euphyllin (0.5% solution in warm water) from the negative pole is the final stage of "renal tuba". Clinical, instrumental and special biochemical studies were performed in comparison with control data obtained in 30 healthy children of comparable age (±) and gender (11 boys and 17 girls).
Results. When studying some indicators of endogenous intoxication in patients with DCP in the active period before treatment, a significant decrease in the relative amount of TCA (P < 0.001), ECA (P<0.001), BCA in serum (P < 0,001), AMP level in urine significantly increased (P < 0.05) (table 1). Along with this, we observed a significant (more than 5-fold) increase in the content of TCA in urine (P< 0.001 - see table 1). A comparative evaluation of endogenous intoxication after treatment in children with DXD, depending on the method of treatment, showed various changes in these indicators (see table 1). Thus, in children with DXP who received conventional therapy (group 1), before discharge from the hospital, the level of AMP in urine not only did not improve, but even a tendency to further decrease (P1 > 0.1) was observed. The level of TCA, ECA, BCA in the serum did not change significantly (P1 > 0.1). Also, we did not reveal positive dynamics of the TCA index in urine (P1 > 0.1, see table 1).
Table 1.- Dynamics of indices of endogenous intoxication of the kidneys in blood plasma and in the urine in patients with CCP, depending on the method of treatment (M ± m) (X ± m)
Indexes Healthy n = 30 Before treatment n = 130 After treatment
1st group. n = 48 2nd group. n = 45 3rd group. n = 37
Blood
TCA. g/l 47.5 ± 0.55 30.1 ± 0.96 P < 0.001 31.0 ± 1.03 P1> 0.1 35.1 ± 1.86 P1 < 0.001. P2 < 0.001 40.1 ± 1.27 P1 < 0.001. P2 < 0.001
ECA. g/l 40.4 ± 3.7 23.4 ± 0.84 P < 0.001 23.02 ± 0.91 P1 > 0.1 282.8 ± 1.55 P1 < 0.001. P2 < 0.001 34.5 ± 1.3 P1 < 0.001. P2 < 0.001
BCA. (ECA\ TCAx100)% 93.0 ± 2.7 77.0 ± 1.3 P < 0.001 73.3 ± 2.4 P1 > 0.1 82.0 ± 1.2 P1 < 0.001. P2 < 0.001 85.9 ± 1.3 P1 < 0.001. P2 < 0.001
Urine
AMP. units 0.136 ± 0.021 2.2 ± 0.02 P < 0.05 0.754 ± 0.047 P, > 0.1 0.605 ± 0.023 Pl> 0.1. P2 > 0.1 0.287 ± 0.012 Pl < 0.05. P2 < 0.05
TCA. g/l 0.20 ± 0.01 4.34 ± 0.094 P < 0.001 4.77 ± 0.18 P. > 0.1 2.14 ± 0.12 Pl < 0.02. P2 < 0.01 0.28 ± 0.06 Pl < 0.001. P2 < 0.05
Note: P - reliability of the difference between indices of healthy children and in children with chronic pyelonephritis. P1 - the reliability of the difference between the indicators before and after treatment. P2 - the reliability of the difference between traditional therapy and the group of children who received RLAT in combination with electrophoresis with about 5% of euphyllin.
We found more positive changes in the indices of endogenous intoxication in patients with the use of RLAT in combination with Kanefron-H (group 2). Thus, there was a decrease in the level of AMP (P1 > 0.1) and TCA (P1 < 0.02) in the urine, a significant increase in TCA (P1 < 0.001), ECA (P1 < 0.001), BCA (P1 < 0.001) in serum compared with similar indicators before treatment. Positive changes were also revealed in comparison with the 1st group for TCA (P2 < 0.001), ECA (P2 < 0.001) and BCA (P2 < 0.001) in serum. Only the content of AMP in urine has not improved (P1, P2 > 0.1). In general, the use of RLAT in combination with Kanefron H in children with DXP had a positive effect on certain parameters of EI, mostly on TCA and ECA, BCA, but less on the level of AMP in the urine.
Patients of the 3rd group were assigned, in addition to RLAT + kanefron-H, a water load and electrophoresis with 0,5% euphyllin. We noted the positive dynamics of practically all studied EI indices in this group. Thus, the content of TCA, ECA, BCA (P1, P2 < 0.001) in blood serum, as well as AMP and TCA in urine not only sig-
nificantly improved in relation to the relevant parameters before treatment and to the parameters after treatment of patients of Groups 1 and 2 (P1, P2 < 0.05), but also reached the level of healthy children (P > 0.1).
Discussion. Our investigations on the study of some EI parameters in patients with DXP in the active period before treatment indicated a decrease in the level of TCA (P < 0.001), ECA (P < 0.001), BCA (P < 0.001) in the blood serum. At the same time, a significant decrease in the parameters of the TCA (P < 0.001) and AMP (P < 0.05) in urine was found. The obtained data are confirmed the information from the literature on the presence of a combined metabolic disorder in DCP [3]. In our opinion, this may be related to DMN, to a certain extent, against which pyelonephritis developed in the patients examined. It potentiates and modifies a stable inflammatory process in the kidneys by irritating the mucous membrane of the urinary tract, reducing the effectiveness of the mechanisms of sanogenesis, thereby creating conditions for a long persistence of uropatho-gens in the kidneys, which causes a significant change in
the EI indices. In addition, before receiving, patients received long courses of antibiotic therapy i.m. and per os. Comparative evaluation of EI after treatment in children with DXD, depending on the treatment method, showed different changes in EI parameters. Thus, in children with DXP who received conventional therapy (group 1), many of the EI indicators studied did not change significantly before discharge from the hospital (P > 0.1). Perhaps this is due to the fact that the introduction of a large number of antibiotics further inhibited the EI indicators. Traditional therapy had no effect on the maintenance of TCA (P > 0.1), ECA in the serum (P > 0.1), and the serum levels of BCA not only did not improve (P > 0.1), but even a trend to an even greater decrease. A significant increase in the TCA content (P1, P2 < 0.001) and ECA in the blood serum (P1, P2 < 0.001) and a decrease in the TCA in the urine (P1 < 0, P1, P2 < 0.001) were observed in the presence of RLAT in combination with Kanefron-H (group 2) 02, P2 < 0.01), compared with similar indicators before treatment. At the same time, inadequate efficiency of RLAT in combination with Kanefron-H in relation to AMP in urine (P1, P2 > 0.1), which play an important role in DHP, in our opinion, requires additional use of water load and electrophoresis with 0,5% euphyllin. Therefore, in addition to RLAT in combination with Kanefron-H, a third group of patients was assigned water loading and electrophoresis with 0,5% eu-phyllin. We noted the positive dynamics of virtually all the studied EI indices in the complex application of the water load + RLAT + kanefron-H + electrophoresis with 0.5% euphyllin. So, the content of TCA, ECA, BCA in the blood serum, TCA in urine not only significantly improved in relation to the corresponding parameters before treatment (P1 < 0.001), but also reached the level of healthy children (P > 0.1). The best results were achieved
with this method of treatment and for AMP in urine, their content decreased almost 4 times (P1, P2 < 0.05).
Summarizing the results of our research, it is necessary to once again focus on the following points. After the conventional treatment for the observation period, there was no significant improvement in the EI indices. Using RLAT in combination with Kanefron-H, we detected a significant improvement in some parameters of EI, a significant increase in TCA and ECA in the serum, a significant decrease in TCA in the urine. AMP in urine decreased with this method of treatment in half. Finally, using the complex water load + RLAT + kanefron-H + electrophoresis with 0.5% euphyllin, it was possible to achieve the best results: recovery of a number of studied parameters (serum BCA) and significant improvement of the rest (TCA, ECA
the urine). All this makes it possible to presume high effectiveness of the proposed methods of therapy in children with DCH (water load + RLAT + kanefron-H + electrophoresis with 0.5% euphyllin) with respect to EI parameters.
Conclusions
1. Patients with DXP with preserved renal function, changes in EI parameters are noted, which requires finding new approaches to treatment aimed at normalizing the signs of endogenous intoxication.
2. The use of RLAT in combination with kanefron-H in the complex therapy of patients with DXP has a positive effect on the main EI indicators.
3. The use of complex treatment of "renal tuba" in DXP is the most acceptable method of therapy. This method contributes to an earlier recovery of TCA, ECA, BCA in the serum and has a positive effect on the state ofAMP and TCA in the urine due to pronounced membrane-stabilizing, antibacterial and detoxification effects.
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