Hydronephrosis in children treatment. Hydronephrosis in children - how to recognize and treat kidney disease. Why does hydronephrosis develop in childhood?

Hydronephrosis of the kidneys in children is pathological condition, which most often refers to a type of congenital developmental anomaly. This disease is characterized by pronounced dilation of the renal pelvis as a result of difficulty or complete cessation of the outflow of urine into the cavity of the ureters.

Acquired pathology occurs as a result of injury to the lower back, the anatomy of the organ is disrupted, inflammation appears in the urinary system, scars form and the process of rotting occurs, which prevents full urination.

In children, this pathology occurs more often than in adults; in infants, symptoms may not be observed; the disease progresses with age. But now it is possible to diagnose a child’s pathology with an ultrasound examination of the mother during pregnancy. In this case, it is better to start treatment immediately after the birth of the baby.

Causes of hydronephrosis in newborns

The reason for the development of this condition may be anatomical narrowing of the lumen of the ureter in the area of ​​its origin from the pelvis, as well as insufficient contractility muscle fibers in their shells. The most common cause of hydronephrosis is considered to be anatomical defects.

Anatomical factors:

  • The presence of valves in the ureteral cavity
  • Abnormal choroid plexus dehiscence and accessory vascular branches
  • Anomalies in the location of the ureters in relation to the renal parenchyma
  • The presence of strands of embryonic origin, which provokes compression and bending of the ureters

If a child has congenital hydronephrosis, its cause lies in a structural disorder of the kidney. Even in the uterine period, during the formation of the internal organ, the urinary tubules may be incorrectly positioned, twisted, or narrowed, which will cause a delay in the outflow of urine.

Numerous studies indicate that the main cause of pathology in most cases is the mother’s poor lifestyle while carrying a child, namely smoking and alcohol. Another cause of congenital hydronephrosis is genetics. The disease is inherited.

Why is hydronephrosis dangerous?

Prolonged retention of urine outflow leads to ischemic damage renal parenchyma with subsequent atrophic changes. Formation rate pathological process depends entirely on how obstructed the urinary duct is.

With a pronounced disturbance of the urinary outflow, the renal pelvis still copes with the urinary function for a short amount of time, but after a certain period of time, hypertrophy of the muscle fibers begins to develop.

Increased pressure in the renal pelvis and ureters can lead to rupture of their membranes, with urine pouring into the retroperitoneal cavity. Due to prolonged stagnation of urine in the upper parts of the urinary system, infectious and inflammatory processes can develop.

Hydronephrosis of the kidneys in children. Symptoms

Symptoms depend on the degree of the disease; in the initial stages, renal hydronephrosis in children proceeds unnoticed.

Hydronephrosis of the first degree in a child.

At this stage, there are no renal dysfunctions, internal organs they work normally, the pathology does not make itself felt, but internal changes occur. When performing an ultrasound, you can notice a slight expansion of the renal pelvis. A skinny baby may develop a belly bump, which parents should pay attention to.

Hydronephrosis of the second degree in a child

During this period, the disease makes itself felt. An ultrasound examination reveals a significant dilation of the renal pelvis and calyces. The second stage of hydronephrosis entails compression of the renal parenchyma due to a large amount of urine. This is followed by atrophy of the kidney tissue, which further reduces the function of the diseased kidney.

The main symptom at this stage is severe pain localized in the lumbar region, irradiation can spread to the periumbilical region. Severity and duration pain syndrome depend on whether the inflammatory process of the urinary system has joined the underlying disease.

Hydronephrosis of the second degree is also characterized by a change in laboratory test parameters in favor of impaired filtration capacity of the renal parenchyma. The child's urine becomes cloudy, and laboratory results indicate that the urine contains a large number of leukocytes and erythrocytes. In infectious diseases, an elevated temperature is observed.

Frequent infectious diseases urinary tract in children may indicate the presence of hydronephrosis.

During palpation, you can feel a tumor-like formation, which can be easily felt even through the anterior wall of the abdomen. Increased blood pressure is also observed.

Hydronephrosis of the third degree in a child

This is the last stage of the pathology, at which all the symptoms appear more clearly. Protein ceases to be processed normally due to an imbalance in water and electrolyte balance. The kidney parenchyma is affected, the second degree symptoms include swelling of the extremities, severe enlargement of the abdomen, bloody issues when urinating.

How to treat?

Treatment of hydronephrosis in children is carried out operational methods, this is the only way to restore normal urine flow. If the functional capacity of the affected kidney is still preserved, patients are advised to undergo surgery to restore normal patency of the ureters. If the kidney has completely ceased its ability to function normally, such children are indicated for a radical surgical procedure. The prognosis for further life activity depends entirely on the severity and neglect of the child’s underlying condition.

There are cases when hydronephrosis in newborns can go away on its own up to a year. The baby is examined every three months, with the first and second degrees of hydronephrosis; if the disease has reached stage 3, it is necessary to urgently treat the child. Surgery for hydronephrosis in children in most cases is carried out endoscopic method. This technique is less traumatic for children than the abdominal method.

During the operation, two small incisions are made through which an endoscope and the necessary devices are inserted. If urinary obstruction is caused by the ureter, plastic surgery is performed. If a large amount of urine has accumulated in the kidney, it will be removed using a catheter. The efficiency of the operation is very high.

Modern technologies make it possible to perform surgery on a child still in the womb, but the risks of this technique are very high, and it can lead to miscarriage.

Rehabilitation period

At the end of the operation, the surgeon places an internal or external drainage system on the child. WITH internal system the baby can be discharged from the hospital within a week. But with the external one you will have to spend about a month in the hospital. During the rehabilitation period after hydronephrosis, antibiotics and uroseptics are prescribed. The child is registered with a urologist. For six months, you must take a general urine test every two weeks. Even if 6 months have passed since the operation, leukocytosis may be detected in the urine, do not worry about this, this is normal.

Hydronephrosis of the kidneys in children is a serious disease, the treatment of which is urgent. If you suspect that your child's kidney function is impaired, be sure to share your suspicions with your doctor.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Congenital hydronephrosis (Q62.0)

Congenital diseases, Pediatrics, Pediatric surgery

general information

Short description

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
And social development
Republic of Kazakhstan
dated November 27, 2015
Protocol No. 17

Protocol name: Congenital hydronephrosis in children

Congenital hydronephrosis -progressive expansion of the pelvis and calyces, resulting from a violation of the outflow of urine in the area of ​​the ureteropelvic segment, which ultimately leads to irreversible changes in the parenchyma and a progressive decrease in the function of the affected kidney.

Protocol code:

ICD-10 code(s):
Q 62.0 Congenital hydronephrosis

Abbreviations used in the protocol:

ALT- Alanine aminotransferase
APF- angiotensin converting enzyme
AST- aspartate aminotransferase
HIV- AIDS virus
ELISA- linked immunosorbent assay
LMS- ureteropelvic segment
MVS- urinary system
MRU- magnetic resonance urography
OZhSS- total iron binding capacity
UAC- general blood analysis
OAM- general urine analysis
RFP- Radiopharmaceutical
SCF- glomerular filtration rate
ESR- erythrocyte sedimentation rate
CCC- the cardiovascular system
Ultrasound- ultrasonography
ECG- Electrocardiogram
EchoCG- Echocardiography
CKD- chronic kidney disease
chronic renal failure- chronic renal failure
maxillofacial area- pyelocalyceal system
DMSA- dimercaptosuccinic (succinic) acid

Date of development of the protocol: 2015

Protocol users: doctors and paramedics of the emergency medical team, doctors general practice, pediatricians, neonatologists, surgeons, urologists.

Classification

Clinical classification:

Classification (Lopatkin N.A.., 1969) :

I - initial;
II - early;
III - terminal.

Classification (Pytel A.Ya., Pugachev A.G., 1977) :
- Primary - congenital, as a result of a malformation of the kidney or upper section ureter.
- Secondary - acquired as a complication of the underlying disease.
- I-initial - signs of hydrocalycosis, excretory function of the kidneys does not suffer;
- II-signs of pyelectasis, moderate atrophy kidney parenchyma, kidney function suffers moderately;
- III-late - kidney function suffers, signs of expansion of the pelvis and calyces throughout, atrophy of the kidney parenchyma;
- IV - terminal: lack of kidney function, significant atrophy of the parenchyma, significant expansion of the pyelocaliceal system.

Clinical picture

Symptoms, course


Diagnostic criteria making a diagnosis:

Complaints and anamnesis:
· asymptomatic;
· decreased appetite;

· increased body temperature up to 39-40ºС, vomiting, nausea;
· aching pain in the lumbar region;

Physical examination:
· pastiness of the face, swelling of the eyelids, blueness under the eyes;
· “blush” on the cheeks;
· dryness of the mucous lips;
tachycardia, possible presence arterial hypertension;
· palpation reveals the presence of a formation (enlarged kidney) of soft-elastic consistency, moderately painful (palpable tumor syndrome);
· weakness, lethargy.

Diagnostics


List of basic and additional diagnostic measures:

Basic (required) diagnostic examinations carried out on an outpatient basis:
· general blood analysis;
· general urine analysis;
· blood chemistry ( total protein and its fractions, urea, creatinine, residual nitrogen, ALT, AST, glucose, total bilirubin, direct and indirect fraction, potassium, sodium, calcium);


· Zimnitsky test;

Additional diagnostic examinations performed on an outpatient basis: No.

The minimum list of examinations that must be carried out when referring for planned hospitalization ( inpatient care): in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out on stationary level in case of emergency hospitalization and after a period of more than 10 days has passed from the date of testing in accordance with the order of the Ministry of Defense:
· general blood analysis;
· general urine analysis;
· biochemical blood test (total protein and its fractions, urea, creatinine, residual nitrogen, ALT, AST, glucose, total bilirubin, direct and indirect fractions, potassium, chlorine, sodium, calcium);
· coagulogram;
· Zimnitsky test.
· bacteriological culture of urine;
· SCF;
· Dopplerography of renal vessels - evaluate hemodynamic disorders (depletion of blood flow) of renal vessels;
excretory urography - if necessary, determine the anatomical and functional state kidneys, pelvis, ureters and bladder;
· voiding cystography - to identify the degree of vesicoureteral reflux.
· histological examination of biological material.

Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations not carried out at the outpatient level are carried out) :
· blood test for sterility with the study of morphological properties and identification of the pathogen and sensitivity to antibiotics;
general radiography of organs abdominal cavity;
Ultrasound of the retroperitoneal organs;
· Ultrasound with a diuretic load (furosemide) - to determine the size of the CL of both kidneys;
· infusion excretory urography with reduced concentration function of the kidneys;
Cystourethroscopy - to identify pathology of the bladder and urethra;
· retrograde pyelography- allows you to clarify the level of obstruction of the LMJ;
· radioisotope dynamic nephroscintography - determines the level of damage to glomerular and tubular function, determines the depth of functional changes and the presence of reserves in hydronephrosis;
Renal scintigraphy with dimercaptosuccinic acid - allows you to assess the degree of impairment functional ability kidneys (foci of non-viable kidney tissue).
· CT/MRU of the retroperitoneal organs - determines the size of the kidneys, the renal function, the level of obstruction and skeletopy;

Diagnostic measures carried out at the stage of emergency emergency care: are not carried out

Instrumental studies:
· Ultrasound of the retroperitoneal organs-increase in size, thinning of the parenchyma, change in the shape of the kidneys, uneven contours, expansion of the central region, increased echogenicity of the parenchyma, with Dopplerography of the vessels of the kidneys - depletion of blood flow.
With stage 1 hydronephrosis - the linear dimensions of the affected and contralateral kidneys do not differ from normal ones. The thickness of the kidney parenchyma is not changed. The dimensions of the pelvis range from 6 to 2 mm with modified calyces;
For hydronephrosis II stages- an increase in the linear dimensions of the affected kidney, expansion of the pelvis more than 20 mm, expansion of the calyces. The thickness of the parenchyma of the affected kidney is reduced, but exceeds 5 mm, there are no changes in the contralateral kidney;
For hydronephrosis III stages - pronounced changes in both kidneys, an increase in the size of the affected (due to hydronephrotic transformation) and contralateral (vicarious hypertrophy) kidneys. There is thinning of the parenchyma in hydronephrotic kidneys (2-3 mm), its compaction and lack of differentiation.
· Ultrasound with diuretic load (Lasix at the rate of 0.5 mg/kg) - determine the size of the CL of both kidneys, evaluate the dynamics of the collector system at the 15th, 30th, 45th, 60th minutes of the study. Normally, maximum expansion of the maxillary joint occurs 10-15 minutes after the administration of Lasix, and a return to its original size occurs by 20-30 minutes;
· Dopplerography of renal vessels - echostructural changes in the vessels of the renal pelvis and upper urinary tract;
· Renal scintigraphy with dimercaptosuccinic (succinic) acid (DMSA) with radiopharmaceuticals - The radiopharmaceutical is fixed in the proximal renal tubules, allows you to evaluate the renal parenchyma without superimposing elements of the collecting system, allows you to visualize foci of non-viable renal tissue, timely establish the stage and assess the dynamics of renal damage;
· excretory urography(10 min, 18 min, 30 min, 1-6 hours ) - coin-shaped expansion of the renal collecting system of varying degrees, expansion of the pelvis (extra-, intrarenal), lack of contrast of the ureter, delayed evacuation contrast agent from the collector system;
· infusion excretory urography(with reduced concentration function of the kidneys) - expansion of the renal collecting system of varying degrees, expansion of the pelvis (extra-, intrarenal), lack of contrast of the ureter, delay in evacuation of the contrast agent from the collector system;
· voiding cystography - the contours and shape of the bladder, the presence of retrograde reflux of the contrast agent into the upper urinary tract, as well as the state of the urethra during voiding;

Indications for consultation with specialists:
· consultation with a pediatrician to exclude concomitant somatic pathology;
· consultation with a cardiologist to exclude CVS pathology;
Consultation with a pulmonologist to exclude pathology respiratory system;
· ENT consultation to exclude nasopharyngeal pathology;
· consultation with a dentist - for sanitation of the oral cavity;

Laboratory diagnostics


Laboratory research:

· UAC - leukocytosis, neutrophil shift to the left, mild anemia and medium degree severity, acceleration of ESR;
· OAM - leukocyturia, proteinuria, bacteriuria, hyposthenuria (decreased concentration function), micro-, macrohematuria;
· blood biochemistry - azotemia (increased levels of creatinine), urea, decreased blood pressure, ferritin, hypokalemia, hypocalcemia;
· Zimnitsky test - decreased concentration function of the kidneys, hyposthenuria (specific gravity of urine 1010), isosthenuria (specific gravity of urine 1015);
· bacteriological culture of urine - bacteriological flora over 10/5 mL/l;
· GFR according to the Schwartz formula GFR = 0.0484 x height (cm)/creatinine (mmol/l) for boys over 13 years old, a coefficient of 0.0616 is used (GFR by stage, see Table 1).
· histological examination: type 1 - the outer diameter of the segment corresponds to the age of the child, sharp thickening of the wall with a decrease in its diameter, hypertrophy and pronounced intracellular hyperplasia of leiomyocytes, increased vesiculation of membranes and smooth muscle cells, an increase in the number of mitochondria, collagen is found in the perimuscular spaces in the form of separate small groups fibers; Type 2 - thinning of the wall, a decrease in the outer and inner diameter of the segment, pronounced atrophy of the muscle layer, sharp clearing of the cell cytoplasm, disappearance of caveolae along the membrane with cases of collagen bells; Type 3 - the walls of the dysplastic segment of the ureter resemble tissue paper in thickness, with a sharply narrowed internal diameter, complete atrophy of smooth muscle cells, surrounded by a connective tissue capsule that has replaced their basal membranes.

Table - 1. GFR by stages in hydronephrosis

Stage Characteristic GFR ml/min/1.73m2
I kidney damage with normal or increased GFR 90 or more
II kidney damage with mild reduction in GFR 60-89
III moderate decrease in GFR 30-59
IV marked decrease in GFR 15-29
V renal failure less than 15

Differential diagnosis


Differential diagnosis:

Table 2. Differential diagnosis hydronephrosis

Sign Congenital hydronephrosis Solitary cyst Megacalycosis
Pain Yes Small cysts are asymptomatic, while giant cysts cause pain No
Edema in later stages rarely No
Arterial pressure does not always increase increases with compression rarely
Increased body temperature with exacerbation of pyelonephritis No No
Local symptoms pain in the lumbar region, in the area of ​​​​the projection of the kidneys pain syndrome with large cysts, No
Dysuria when associated with a urinary tract infection No
Leukocyturia when associated with a urinary tract infection when associated with a urinary tract infection when associated with a urinary tract infection
Hematuria transient Yes rarely
Palpable tumor syndrome more often with gradual increase for giant kidney cysts Yes
Decreased concentration function hypo-, isosthenuria with signs of chronic renal failure No No
Kidney ultrasound an increase in the size of the kidney, thinning of the parenchyma, uneven contours, expansion of the ventricular region, and with Dopplerography of the renal vessels - depletion of blood flow. homogeneous liquid medium at the site of the renal tissue defect the size of the kidneys is normal, the surface is smooth, the cortical layer of the kidney is of normal size and structure, the medulla is underdeveloped and eroded, the papillae are flattened and poorly differentiated, the dilated calyces pass into the intrarenal pelvis, the LMS is formed correctly, not narrowed.
Excretory urogram coin-shaped expansion of the renal collecting system of varying degrees, expansion of the pelvis (extra-, intrarenal), lack of contrast of the ureter, delayed evacuation of the contrast agent from the collector system a rounded homogeneous shadow with thin walls limiting it from the surrounding parenchyma, the pelvis is compressed, the cups are pushed back, moved apart (symptom of “spread mouth”) the structure of the kidney is not changed, the LMS is patent, the excretory-evacuation function is not impaired.

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Treatment


Treatment goals:

Elimination of obstruction in the area of ​​the UJJ - resection of the UJJ with the imposition of a pyeloureteral anastomosis, reduction of the inflammatory process in the renal tissue, slowing down the rate of progression of chronic renal failure.

Treatment tactics:
In case of congenital hydronephrosis of I-II degree with no signs of exacerbation of pyelonephritis, treatment (conservative and surgical) is not indicated. If there are signs of exacerbation of pyelonephritis, it is necessary to carry out conservative treatment aimed at eliminating the microbial inflammatory process and restoring functional disorders in the kidneys.
With congenital hydronephrosis III and terminal stage surgical treatment is indicated. If there are signs of exacerbation of pyelonephritis, it is necessary to carry out conservative treatment at the beginning aimed at eliminating the microbial inflammatory process and restoring functional disorders in the kidneys, and only after 1-3 months surgical treatment is indicated as planned.

Surgical intervention:
Indications for surgery - in case of stage 3 hydronephrosis, when there is an anatomical or functional obstruction in the area of ​​the urinary tract, causing stasis of urine and expansion of the collecting system of the kidney.
Contraindications There are absolute and relative:
to absolute contraindications relate:
· serious condition patient due to severe somatic;
· congenital pathology of cardio-vascular system;
· violation of the blood coagulation system.
To relative contraindications relate:
· catarrhal phenomena, viral and bacterial infections;
· protein-energy deficiency II - III degree;
· anemia;
· digestive disorders;
· diseases of the respiratory organs, their catarrhal conditions; unsatisfactory condition skin(pyoderma, recent phenomena of exudative diathesis, infectious diseases in acute period, chronic renal failure stage 3).

Surgical intervention provided in an inpatient setting:

Types of operation:
Ljumbotomy:
· LMS plastic surgery according to Haynes-Andersen-Kucher, stenting/pyelostomy;
· nephroureterectomy (drainage of the retroperitoneal space).
Laparoscopic removal of hydronephrosis, stenting/pyelostomy.

Non-drug treatment:
Mode - I, II (protective);
Diet No. 15, for signs of chronic renal failure - diet No. 7.

Drug treatment:
Upon appointment antibacterial therapy it is necessary to take into account the sensitivity of the isolated pathogen culture to antibiotics.
IN postoperative period Therapy with the following drugs is recommended:
For antibacterial purposes, monotherapy with one of the following drugs is recommended for the prevention of postoperative complications according to indications: 2nd generation cephalosporins (Cefuroxime) or 3rd generation (Ceftriaxone). Cefuroxime 70-100 mg/kg/day x 2 times intravenously - for antibacterial purposes for 10-14 days or ceftriaxone - newborns 20-50 mg/kg x 1-2 times a day, children under 12 years old 20-80 mg/ kg, children over 12 years old 1-2 grams x 1 time per day or 500 mg -1 gram x 2 times per day, intravenous treatment for 10 - 14 days;
metronidazole for children under 1 year old - 125 mg/day, 2-4 years old - 250 mg/day, 5-8 years old - 375 mg/day, over 8 years old - 500 mg/day x 2 times a day day, IV, course of treatment - 5 days - for antiaerobic purposes;
· chloropyramine ½-1/4 tablet x 2 times a day orally or loratadine ½ tablet x 1 time orally for desensitizing purposes for 7-10 days;
· papaverine from 6 months to 14 years 5-20 mg orally or intramuscularly - for antispasmodic purposes;
· tramadol 0.1 ml/year x 3 times, IV, IM - for analgesic purposes for 3-5 days after surgery;
· for antihypertensive purposes, capoten 0.3 mg/kg up to a maximum dose of 6 mg/kg x 2-3 times a day orally as indicated;
co-trimoxazole from 3-5 years 240 mg x 2 times, from 6-12 years 480 mg x 2 times a day orally for 10 days1 or erythromycin up to 14 years 20-40 mg/kg x 4 times a day, over 14 years 500 mg x 4 times a day after 10 days or nitrofurantonin 5-8 mg/kg x 4 times a day orally for 10 days or nitroxoline over 5 years 0.2-0.4 g x 4 times a day, up to 5 years 0.2 g per day orally for 10 days - for uroseptic purposes;
· albumin 10% 10-15 ml/kg IV, drip - correction of protein metabolism disorders;
· FFP at the rate of 10-15 ml/kg, IV, drip - for hemostatic purposes;
· red blood cell mass - for replacement purposes it is prescribed at the rate of 10-15 ml/kg, IV, drip;
· heparin 200 units/kg subcutaneously x 2 times a day for anticoagulant purposes;
· metoclopramide 0.1 mg/kg x 2-3 times a day IM, IV - to normalize organ tone digestive tract;
If complications develop, treatment is carried out accordingly clinical protocols developed complications.

Drug treatment provided at the emergency stage:
At renal colic antispasmodics are prescribed:
· papaverine from 6 months to 14 years 5-20 mg orally or intramuscularly;
When body temperature rises to 38-40* degrees, antipyretic drugs:
· physical methods cooling (alcohol solution);
· paracetamol from 9 -12 years 2 g from 3-6 years 60 mg/kg orally or suppositories 2-3 times a day perrectum
· or ibuprofen 20-30 mg/kg x 3-4 times a day orally.

Other types of treatment: No.

Indicators of treatment effectiveness [ 15]:
· restoration of patency of the lumbar system;
· no signs of exacerbation of pyelonephritis;
· pain relief;
· normalization of arterial hypertension;
· stabilization of impaired renal function;
· improvement of clinical, laboratory and instrumental indicators: reduction of azotemia, creatinine, absence of leukocytosis with a neurophilic shift to the left, reduction of leukocyturia, proteinuria, absence of bacteriuria, ultrasound MBC with Doppler (reduction of the linear dimensions of the operated kidney, reduction of heart rate, expressed by improvement of peripheral blood flow); excretory urography (restoration of the patency of the urinary tract, reduction in the size of the peripheral joint, satisfactory excretory-evacuation functions);
· absence or relief of complications (pyelonephritis) of congenital hydronephrosis;
· no relapse in the postoperative period.

Drugs (active ingredients) used in treatment

Hospitalization


Indications for hospitalization indicating the type of hospitalization:

Indications for planned hospitalization:
· periodically recurring aching pain in the abdomen or lumbar region, the presence of signs of hydronephrotic transformation on ultrasound.

Indications for emergency hospitalization:
· increased body temperature, aching pain in the lumbar region, swelling, changes in urine tests (leukocyturia, proteinuria, bacteriuria), attacks of renal colic.

Prevention


Preventive actions:
· Diet;
· Security mode;
· Sanitation of foci of infections;
· Taking ACE inhibitors for signs of arterial hypertension, nephroprotectors for renal failure according to indications;
· Prevention of complications: early prenatal and postnatal diagnosis, timely hospitalization and surgical treatment reduce the risk of developing complications of congenital hydronephrosis.

Further management:
· in the postoperative period, children with congenital hydronephrosis are in the department intensive care and resuscitation (the first day after surgery);
· control of filtration and concentration function of the kidneys;
· control of OAM, blood pressure, ultrasound MVS;
daily dressings of postoperative wounds;
· control of drainage tubes;
· removal of sutures on 7-10 days;
· all children operated on for congenital hydronephrosis require clinical observation;
· a maintenance course of uroseptics (biseptol, furadonin, furagin, nitroxoline, furamag, furazolidone, erythromycin in an age-appropriate dosage) alternating every 10 days is carried out for 3 months according to the scheme after discharge from the hospital;
· control of OAM once every 10 days for 6 months;
· control x-ray examination after surgery 6 months later as planned;
· clinical examination and volume therapeutic measures carried out on the basis of immediate and long-term results surgical intervention within 5 years.

Information

Sources and literature

  1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015
    1. List of used literature (valid research links to the listed sources in the text of the protocol are required): 1) Isakov Yu. F., Dronov A. F.// In the book. Pediatric surgery: National leadership/– M., GEOTAR - Media, 2009. – P. 583-589.1164 2) Pugachev A.G.//Pediatric urology. Guide for doctors. - M: “GEOTAR – Media”, 2009. - .S. 3) Erekeshov A.E.//Modern methods of diagnosis and treatment of congenital hydronephrosis in children. /Book: Astana, 2011. – P. 116. 4) Zorkin S.N.//Multiple obstructions of the urinary tract in children./ – M., - MIA, 2008. – P. 138. 5) Emad-Eldin S. , Abdelaziz O., El-DiastyT.A.// Diagnostic value of combined static-excretory MR Urography in children with hydronephrosis./J Adv Res. 2015 Mar;6(2):145-53. 6) Severgina L.O., Gurevich S.I.//Ultrastructural assessment of the role of dysangiogenesis in congenital hydronephrosis./ArkhPatol. 2014 Nov-Dec;76(6):51-5. 7) HsiR.S., Holt S.K., Gore J.L., LendvayT.S., Harper J.D.//National Trends in Followup Imaging after Pyeloplasty in Children in the United States./J Urol. 2015 Sep;194(3):777-82. 8) Chandrasekharam V.V.// Laparoscopic pyeloplasty in infants: Single-surgeon experience./ J Pediatr Urol. 2015 Oct;11(5):272. 9) Garg R.K., Menon P., NarasimhaRaoK.L., Arora S., BatraY.K.//Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique./Indian AssocPediatr Surg. 2015 Jan;20(1):32-6. 10) Al-Mashhadi A., Nevéus T., Stenberg A., Karanikas B., Persson A.E., Carlström M., Wåhlin N.//Surgical treatment reduces blood pressure in children with unilateral congenital hydronephrosis./J Pediatr Urol . 2015 Apr; Apr;11(2):91.e1-6. 11) HsiR.S., Holt S.K., Gore J.L., LendvayT.S., Harper J.D.//National Trends in Followup Imaging after Pyeloplasty in Children in the United States./J Urol. 2015 Sep;194(3):777-82 12) Herz D., Merguerian P., McQuiston L.//Continuous antibiotic prophylaxis reduces the risk of febrile UTI in children with asymptomatic antenatal hydronephrosis with either ureteral dilation, high-grade vesicoureteral reflux, or ureterovesical junction obstruction./J Pediatr Urol. 2014 Aug;10(4):650-4. 13) EdlinR.S., Copp H.L.//Antibiotic resistance in pediatric urology./TherAdv Urol. 2014 Apr;6(2):54-61. 14) Zareba P., Lorenzo A.J., Braga L.H.//Risk factors for febrile urinary tract infection in infants with prenatal hydronephrosis: comprehensive single center analysis./J Urol. 2014 May;191(5 Suppl):1614-8. 15) Hydronephrosis and Hydroureter Treatment & Management, March 4, 2015.

Information


List of protocol developers with qualification information:
1) Dzhenalaev Bulat Kanapyanovich - doctor medical sciences, professor, RSE at the PVC "West Kazakhstan State medical University named after Marat Ospanov”, Head of the Department of Pediatric Surgery;
2) Aigul Saparbekovna Botabaeva - Candidate of Medical Sciences, acting as Associate Professor of the Department of Pediatric Surgery of Astana Medical University JSC;
3) Kalieva Sholpan Sabataevna - candidate of medical sciences, associate professor of the RSE at the Karaganda State Medical University, head of the department clinical pharmacology And evidence-based medicine.

Disclosure of no conflict of interest: No.

Reviewer: Mailybaev Bakytzhan Muratovich - Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Surgery of JSC National Scientific Medical Center for Maternity and Childhood.
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Kidney diseases in childhood most often due to various disorders in intrauterine development, as regards newborns, and past inflammatory diseases of the urinary system in older people. Hydronephrosis is somewhat more common in children than in adults. If the disease is not detected in time and you do not seek treatment medical care the consequences can be very different.

The statistics of children dying at birth from bilateral hydronephrosis is not reassuring due to the lack of adequate diagnosis in the prenatal period. However, if a child’s congenital pathology is not very pronounced, it may not be detected even after birth. With age, the severity of hydronephrosis begins to progress, which inhibits kidney function. Therefore, mothers should know about this disease in order to consult a doctor in time, where the child can be given full assistance.

Why does infantile hydronephrosis develop?

Hydronephrosis can be primary, which develops as a result of congenital anomalies, and secondary, which appears as a complication of existing or past diseases. The causes of hydronephrosis in children are often congenital. Among these are:

  • Congenital ureteral stenosis
  • Segmental dysplasia
  • Horseshoe kidney
  • Accessory renal vessel crossing the ureter
  • Incorrect exit of the ureter from the kidney.

This video explains the causes of kidney problems in children:

As a result, the outflow of urine from the renal pelvis is disrupted, and it accumulates in the kidneys. Congenital hydronephrosis in a child can be initially diagnosed during pregnancy. And acquired or secondary hydronephrosis manifests itself at different ages. They lead to him:

  • Benign and malignant tumors of the abdominal organs
  • Kidney neoplasms
  • Inflammatory infiltrates in the retroperitoneal space
  • Chronic inflammatory diseases of the urinary system.

Depending on the extent of the lesion, the pathology can be unilateral or bilateral. Kidney hydronephrosis in children is bilateral in 15% of cases. Moreover, the disease is detected 2.5 times more in boys than in girls.

What clinical manifestations accompany the disease?

Symptoms of hydronephrosis depend on the severity of the disease. The presence of pathology is indicated by the following phenomena:

  • Lower back pain on the affected side
  • Heaviness in the stomach
  • Sensation of a palpable mass in the abdominal cavity
  • Blood in urine
  • Arterial hypertension
  • Weakness and increased fatigue
  • Nausea, vomiting, stool disorders.

In young children, the timely detection of hydronephrosis depends on the attentiveness of the mother.

After all, if an adult child can say what is bothering him, then babies show their condition by crying, worrying, bad sleep, breast refusal. Sometimes mothers notice that the amount of urine in the child changes, both upward and downward, and this is also a sign of hydronephrosis.

What happens to a kidney affected by hydronephrosis?

With hydronephrosis, under the pressure of accumulated fluid, the kidney becomes rounded and enlarged. The pelvis and calyces are stretched, and the cortex and medulla are thinned, which leads to a rapidly progressive decline in the function of the urinary system.

In a child, grade 1 hydronephrosis practically does not cause clinical manifestations. And starting from stage 2, various complaints appear.

Visible changes in the kidneys during pathology are as follows:

  • The first stage - the pelvis is filled with fluid, the kidney is not enlarged
  • The second stage - the fluid is in the pelvis and calyces, which leads to a slight enlargement of the organ
  • Third stage - the kidney is significantly enlarged, the cortex and medulla are greatly thinned
  • The fourth stage - the kidney substance is absent, the organ is completely filled with urine and does not function.

How is pathology diagnosed in children?

Congenital hydronephrosis in children is detected from the 15th week intrauterine development. For this purpose, ultrasound is used to determine the expansion of the renal collecting system and other pathologies of the development of the urinary organs. After diagnosing the disease in the fetus, the issue of immediate treatment or monitoring the further development of the disease is decided. Medical tactics depends on the general condition of the mother and child, as well as on the severity of the pathology.

The only problem with diagnosing acquired hydronephrosis is the late presentation of patients for medical help.

Modern examinations make it possible to detect the disease at the very beginning of its development. For this purpose, laboratory and instrumental methods research. From laboratory diagnostics What is important is a general urine test, which detects blood, protein and other nonspecific signs that indicate the presence of a pathological process in the kidneys, but are not diagnostic signs of hydronephrosis.

For example, protein in a child’s urine after a cold may indicate past illness, about the presence of pyelonephritis and glomerulonephritis, but can also be detected with hydronephrosis. Therefore, if, after a general urine test, the doctor suggests using additional research methods to clarify the cause of the pathology, then you should not refuse.

Among additional methods hydronephrosis studies are confirmed:

  • During ultrasound examination
  • When performing contrast radiography
  • By computed tomography
  • On magnetic resonance imaging.

Many mothers are interested in the question: is the examination harmful? To which we can safely answer in the negative. After all, the diagnosis of hydronephrosis mainly involves the use of non-invasive diagnostic methods. Certainly, radiographic examination carries a certain radiation exposure, but it is insignificant. After hydronephrosis is detected, the doctor prescribes complex treatment, which is selected individually for each child.

Possible complications of hydronephrosis

The most common complication hydronephrosis is the addition of a secondary infection. Due to stagnation of urine, bacteria have the opportunity to grow and reproduce. Getting into the kidney from underlying departments urinary system, they cause pyelonephritis, which further worsens the condition of the body.

Symptoms of pyelonephritis are:

  • Temperature rises to 38-39 degrees
  • Pain in the lower abdomen when urinating
  • Urinary retention
  • Urination in small portions.

Hydronephrosis grade 3 in children without appropriate treatment is complicated by chronic renal failure. This is very serious pathology, which requires regular monitoring and lifelong treatment. The only way to get rid of kidney failure is to perform an organ transplant.

The worst complication is that there is a possibility of dying from hydronephrosis if it is not treated. Death occurs due to chronic renal failure and poisoning of the body harmful products which are normally excreted in the urine. Moreover, it should be remembered that hydronephrosis of the kidney cannot spontaneously go away without treatment.

Hydronephrosis of the kidney in children develops gradually, but it is impossible to say exactly when the function of the urinary system will begin to be irreversibly impaired. Therefore, treatment of the disease should begin immediately after the discovery of the pathology, because in one child the pathology in stage 1 may exist for 10 years, while in another, renal failure will occur in 2-3 years without treatment.

An anomaly in the development of the urinary system, which is characterized by expansion of the renal cavity and pyelocaliceal system in the fetus due to obstructed outflow of urine, is defined as congenital hydronephrosis. The disease is detected while the child is in the mother’s womb by ultrasound examination. In the absence of the opportunity to examine the fetus, these disorders in the genitourinary system are diagnosed at a later time: after birth or at an older age, but with such serious complications as urolithiasis, pyelonephritis, hypertonic disease, kidney failure.

The underlying causes and timing of pregnancy directly affect the degree of development and formation of the disease. At 15 weeks, an ultrasound can already detect the kidneys and bladder of the fetus, and at 18-20 weeks the organs and their structure are clearly visible. The easiest way to identify abnormalities in the fetal body is at 20 weeks of pregnancy. The production of hypotonic urine by the kidneys begins to occur between 5 and 9 weeks and gradually increases. Complete or partial blockage of the urinary tract, which is the result of underdevelopment of one or another part of the corresponding organ, can cause antenatal hydronephrosis. This condition is not always a pathology, but with significant obstruction, renal tissue can be injured.

Contents of the article:

Causes of the disease and characteristic changes in the body

The development of the disease occurs due to an increase in the capacity of the cups and changes in their configuration, which are influenced by high intrapelvic pressure, and leads to the following consequences:

  • organs become round in shape
  • the necks of the cups expand and shorten,
  • the wall of the pelvis becomes thinner,
  • death of nerve endings
  • obstruction of lymphatic and blood vessels pelvis.

As a result, the final stage of hydronephrosis is characterized by the presence of a pelvis in the form of a thin-walled sac, consisting mainly of coarse fibrous connective tissue.
The main causes of congenital hydronephrosis are:

  • manifestation of a pathological factor during intrauterine development of the fetus,
  • genetic predisposition to congenital disorders,
  • urinary tract dyskinesia,
  • retrocaval location of the ureters,
  • disorders associated with the development of the renal artery,
  • congenital obstruction of the urinary tract.

The causes of congenital hydronephrosis can be various developmental abnormalities genitourinary system, among which:

  • narrow lumen of the ureter,
  • pathological torsion and abnormal direction of the ureters,
  • abnormal size and structure of the vessels, due to which they wrap around the ureters and narrow their lumen.

Older children and adolescents may develop acquired hydronephrosis. The reasons for its appearance may be:

  • lower back injuries,
  • inflammatory processes in the urinary organs and primarily in the ureters,
  • urolithiasis disease,
  • postoperative complications.

Symptoms

There are three degrees of development of hydronephrosis. The clinical picture is increasing.

So, the first degree is asymptomatic, affecting the kidney.

The second stage means impaired renal function, its signs:

  • pain in the lumbar area,
  • decrease in daily urine volume,
  • the appearance of bloody clots in the urine,
  • promotion blood pressure with headaches, nausea, vomiting and general weakness,
  • intoxication of the body, accompanied by an increase in body temperature.

The manifestation of the disease of the third degree coincides with the almost complete death of the kidney. In this case, children experience:

  • increase in body temperature,
  • drowsiness,
  • apathy,
  • decreased daily urine output,
  • significant amount of blood in the urine, enuresis,
  • swelling of the body with very dry skin,
  • significant pressure surge.

Congenital pathology can be detected by screening ultrasound after the 14th week of pregnancy.

Diagnosis of hydronephrosis in a child

Additional research is needed to confirm the diagnosis and determine the causes in older children and adolescents. The main ones are:

  • general and biochemical blood test,
  • clinical urine test,
  • Ultrasound of the abdominal organs,
  • x-ray with contrast injection,
  • MRI or computed tomography,
  • nephroscintigraphy.

Complications

The consequences of hydronephrosis in a child can be divided into physiological and psychological.

The first group includes many infectious lesions of the genitourinary system, the most dangerous among them:

  • urolithiasis disease,
  • renal failure,
  • chronic cystitis,
  • recurrent pyelonephritis.

Psychological problems can arise in conscious childhood due to manifestations of the disease, such as enuresis and severe swelling. And when a catheter is installed, communication with peers can become problematic.

Treatment

What can you do

In most cases, hydronephrosis is congenital. It's difficult to prevent to the expectant mother worth giving up bad habits since the moment of pregnancy planning.

During pregnancy, screening ultrasounds should be performed, which can indicate the presence of the disease. In this case, as the disease progresses, it is possible to perform surgery even in the prenatal period and several months after birth.

Do not refuse surgery under any circumstances; this is the only effective treatment option for second and third degree hydronephrosis.

If the disease was identified during a preventive examination at the first stage, then it is possible to use conservative treatment. It is important to take the medications exactly as prescribed by the doctor, observing the dosage, frequency and duration of the course.

What does a doctor do

When clinical picture for childhood hydronephrosis it is necessary to carry out additional research. Blood and urine tests can only make a diagnosis late stages diseases.

When making a diagnosis, it is important to study the reasons for its occurrence, after which the specialist develops an individual treatment regimen.

Pharmacotherapy is possible only at the first stage of the disease. The doctor may prescribe a course of antibiotics and medications.

If hydronephrosis is detected in a child in the second stage, it is necessary surgical intervention. Depending on the causes and course of the disease, several surgical options are possible:

  • plastic surgery - creation of an artificial connection between the ureter and kidney,
  • ureteral stenting - strengthening the entrance of the ureter with a tube of the appropriate diameter,
  • nephrostomy - insertion of a catheter into the kidney, which will collect urine into an external urinal.

At the third stage of the disease, it is possible to install a catheter; if the kidney is significantly damaged, it is recommended to remove it to avoid intoxication of the body.

Prevention

Hydronephrosis in children is in most cases a congenital pathology that is difficult to prevent. For prevention, a pregnant woman should give up bad habits, healthy image life and eating right.

The best prevention is timely diagnosis of the disease and its prompt treatment. Hydronephrosis of the first degree in children is easily treatable.

During treatment and after its completion, it is important to follow a diet to prevent relapses or exacerbation of the disease. A dietary feature of children diagnosed with hydronephrosis is drinking plenty of water and limited use salt and spices.

Also protect your children from hypothermia, back and lower back injuries, and monitor the daily volume of urine.

IN adolescence talk with your child about health, the need to take care of it, preventive measures and their importance.

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