Hyperbaric Oxygenation in the Combined Treatment of Acute Pyelonephritis

The dissertation is devoted to the study of the role of hyperbaric oxygenation (HBO) in the combined treatment of acute pyelonephritis. The work summarizes data on clinical manifestations, functional disturbances, and features of the disease course at different stages, including purulent-destructive forms. The study evaluates indicators of the systemic inflammatory response and multiple organ failure, the leukocyte intoxication index, glomerular filtration rate, central and renal hemodynamics, as well as the state of immune reactivity. Particular attention is given to the rationale for including HBO in conservative and postoperative treatment regimens and to the analysis of the mechanisms of the method's positive effect. In addition, an experimental study on laboratory animals with histological assessment of the influence of HBO on the renal parenchyma has been carried out.

Acute pyelonephritis accounts for 14–22% of all kidney diseases (Lopatkin N.A., 2004; Sinyakova L.A., 2002; Donskov V.V., 2004; Yanenko E.K., 2007) and represents a serious clinical problem associated with the difficulty of selecting diagnostic approaches and optimal therapeutic tactics for this category of patients (Bernikov E.V., 2008; Loran O.B., Pushkar D.Yu., Rasner P.I., 1999; Safarov R.M., 2005). According to various researchers, purulent-destructive forms of acute pyelonephritis develop in 5–33% of patients (Lopatkin N.A., 1998; Malashchitsky D.A., 2006).

Occurring as an independent disease or complicating the course of many other urological diseases, acute pyelonephritis often leads to the loss of a vitally important organ, the kidney. In complicated cases, when urosepsis develops against the background of purulent-destructive pyelonephritis, mortality reaches 28.4–80% (Lopatkin N.A. et al., 1991; Dembry L.M., Andriole V.T., 1997).

Ischemic and hypoxic processes in renal tissue constitute an important pathogenetic link in the development of inflammation (Chugaev V.V., 2008). Hypoxia affects renal function, the effectiveness of ongoing therapy, and the progression of the pathological process (Denisenko I.L., 1981; Lagutina A.A., 2004). In addition, renal hypoxia may cause systemic arterial hypoxemia, which develops as one of the components of the multiple organ failure syndrome and is especially common in purulent-destructive forms of pyelonephritis. Therefore, the management of hypoxemia in patients with acute pyelonephritis should be considered an integral part of the complex of therapeutic measures. The influence of hyperbaric oxygenation on the course of acute inflammatory processes in the kidneys continues to be a subject of clinical study and discussion, and this issue is considered insufficiently explored (Baydin S.A., Gramenitsky A.B., Rubinchik B.A., 2008).

It is important to note that traditional methods of treating acute pyelonephritis do not always lead to recovery. Unsatisfactory treatment outcomes in patients with purulent-destructive pyelonephritis in the postoperative period are due to significant impairment of renal function and to hospital-acquired infection resistant to most antibacterial drugs (Bovbalan A.V., 2004; Antonova V.E. et al., 2007). All this provides a rationale for the broad introduction of efferent methods of detoxification, in particular hyperbaric oxygenation, into urological and surgical clinics (Lopatkin N.A. et al., 1999; Chugaev V.V., 2008).

At present, the treatment of acute pyelonephritis, especially its purulent forms, is carried out mainly in urological clinics based at large medical institutions, primarily regional and multi-profile city hospitals. At the same time, in central district hospitals such patients are managed by a urologist together with a surgeon, mainly in surgical departments (Rafalsky V.В., 2006). Therefore, any progress in the treatment of various forms of acute pyelonephritis is of interest both to urologists and to surgeons. From a surgical standpoint, this problem can be considered as a variant of surgical infection with all the corresponding consequences. Consequently, the improvement of any therapeutic approach will undoubtedly contribute to a better clinical course of the disease in both specialized and non-specialized medical departments.

The above considerations determined the conduct of the present study.

Aim of the study

To improve the outcomes of treatment of acute pyelonephritis through the use of hyperbaric oxygenation as part of combined therapy.

Objectives of the study

1. To study the clinical manifestations and functional changes in the body at various stages of acute pyelonephritis.

2. To study the clinical effectiveness of hyperbaric oxygenation at various stages of acute pyelonephritis and to identify the mechanisms of the method's positive influence.

3. To study the effect of hyperbaric oxygenation on morphological changes in the renal parenchyma in acute pyelonephritis.

Scientific novelty of the study

1. It has been established that in acute pyelonephritis, a decrease in glomerular filtration rate occurs against the background of an increase in the resistance index and pulsatility index of the segmental renal arteries. The degree of disturbance is greater in destructive forms of the disease.

2. It has been shown that, in the combined treatment of acute pyelonephritis, hyperbaric oxygenation improves the course of the disease, as manifested by a reduction in intoxication, in the frequency of the systemic inflammatory response, and in multiple organ failure. One of the mechanisms of the therapeutic effect of the method is the restoration of immunity and improvement of renal blood flow.

3. In an experiment on animals with a model of acute pyelonephritis, hyperbaric oxygenation reduces the inflammatory response in renal tissue. The reduction of alterative and exudative processes is more pronounced in the non-obstructive form of the disease.

Practical significance

1. It has been established that the proportion of organ-preserving operations at various stages of acute pyelonephritis reaches 70%.

2. The significance of the systemic inflammatory response and multiple organ failure in the clinical course of the disease has been defined. Stabilization or an increase in their frequency indicates insufficient effectiveness of the therapy being administered.

3. It has been shown that a decrease in glomerular filtration rate occurs against the background of worsening parameters of renal hemodynamics.

4. Indications for the use of HBO in the conservative treatment of acute pyelonephritis and in the postoperative period have been determined, and the mechanisms of the positive effect of the method have been identified.

5. The anti-inflammatory effect of hyperbaric oxygenation on the renal parenchyma in acute pyelonephritis has been established. It has been noted that, in the experiment, the positive effect of the method is observed after 10 HBO sessions.

Main statements for defense

1. Acute pyelonephritis develops more often in women under 60 years of age. Obstructive pyelonephritis is observed in 60% of patients. The pre-hospital period in 80% of cases lasts from 2 to 7 days from the onset of the disease. Escherichia coli and Staphylococcus aureus dominate the urinary microflora.

2. In destructive forms of acute pyelonephritis, apostematous pyelonephritis and renal carbuncle predominate. Among surgical interventions, nephrectomy is most frequent in cases of renal abscess.

3. Hyperbaric oxygenation is indicated both in the conservative treatment of acute pyelonephritis and in the postoperative period. The mechanisms of the positive effect of the method are associated with anti-inflammatory and detoxifying action, immunostimulation, and improvement of hemodynamics and function of the renal parenchyma.

Implementation of the research results

The results of the study have been implemented in practice in the urological departments of the medical unit of OAO «Avtodizel» and in the surgical departments of MUZ «Clinical Hospital No. 9» of the city of Yaroslavl, and are used in lectures and practical classes for 4th-, 5th-, and 6th-year students of the pediatric and medical faculties of the Yaroslavl State Medical Academy.

Approval of the work

The main directions and results of the research presented in the dissertation were reported at the All-Russian Conference of General Surgeons with international participation, Yaroslavl, 2007; the 5th Scientific and Practical Conference of Surgeons of Northwest Russia, Petrozavodsk, 2007; the Scientific and Practical Conference «Current Issues of Infectious Pathology in Urology and Gynecology», Saint Petersburg, 2007; the All-Russian Scientific Conference with international participation «Social Aspects of Surgical Care for the Population in Modern Russia», Tver, 2008; the 50th Scientific and Practical Conference dedicated to the 60th anniversary of the Yaroslavl Regional Clinical Hospital, Yaroslavl, 2008; and at a meeting of the Regional Urological Society, 2009.

Publications

On the topic of the dissertation, 11 publications have been issued, of which 7 in central print, including 1 in a journal included in the list of the Higher Attestation Commission (VAK) of the Russian Federation.

Volume and structure of the dissertation

The dissertation is presented on 135 pages of typewritten text and consists of an introduction, a literature review, four chapters of original research, a general conclusion and discussion of the obtained results, conclusions, and practical recommendations. The bibliography includes 165 domestic and 62 foreign sources. The dissertation is illustrated with 30 tables and 27 figures.