Modern aspects and methods of diagnostic and treatment of the acute pyelonephritis in patients with diabetes mellitus

Abstract

Introduction: The importance and the relevance of the study is based on the high prevalence of diabetes mellitus (DM) in the general population and on the high risk of these patients to develop urinary tract infections, but also on serious complications (kidney abscesses, emphysematous pyelonephritis, necrotic papilitis, urosepsis etc.) that can occur due to late diagnosis.The factors which contribute to the increased risk of UTIs are: the immunological defects, the development of vesicoureteral reflux as a result of diabetic neuropathy, increased levels of glucose in the urine, which support the colonization of the micro-organisms.

Materials and methods: The study group included 42 patients with acute pyelonephritis (22 with DM, 20 without DM). There were 28 women (15 with DM, 13 without DM) and 14 men (7 with DM and 7 without DM) with age from 26 till 75 years (the average age 51,8 years). The distribution by the type of diabetes: 16 patients had Type 2 diabetes and 6 patients had Type 1 diabetes.

Results: The clinical manifestations were dominated by general signs of toxicity (weakness, headache, fever) inclusively nausea, with scarce local manifestations. The diagnosis was confirmed using laboratory and instrumental methods: besides the classical methods (urine analysis, urine culture etc.), a major role in early establishing of diagnosis had ultrasonography (100% of patients), intravenous urography (27,2%) - these had an important role in the differential diagnosis of non-destructive and destructive-purulent pyelonephritis. Also the computed tomography (22,7 % of patients) was very useful – it was important in difficult cases for the differentiation of serous and purulent forms of acute pyelonephritis. For diabetic patients was typical the prevalence of destructive-purulent forms (77,2%) compared to serous forms. The treatment was conservative and surgical (the conservative treatment: urinary drainage with ureteral catheter “Pigtail”(45,4%), antibacterial therapy, detoxifying therapy, antidiabetic therapy and the plasmapheresis (35% of patients) has proved its efficacy with a decreased mortality compared with the control group. The basic criterion of differential diagnosis of purulent forms of acute pyelonephritis in patients with DM is the efficacy of conservative treatment. The absence of positive dynamics usually indicate a purulent complication and requires surgery on the affected kidney. Eight (40%) patients with purulent complications were operated–nephrectomy-4 patients(18,2%), the drainage of kidney abscess–3 patients(13,6%), the drainage of paranephrium -1 (4,5%).

Conclusion: Pyelonephritis in patients with DM is a complex problem with an increased rate of purulent complications which aggravate the patient’s condition, with a poor prognosis. The diagnosis plan at these patients requires simultaneous use of clinical, laboratory and instrumental methods for the appreciation of kidney’s function disorders and for early detection on purulent complications. The use of plasmapheresis in the complex treatment of these patients has significantly contributed to the increasing of the treatment efficacy, which justifies it’s practical application.