梗阻性肾病

　　造成尿路梗阻主要原因有输尿管本身，以及输尿管以外两大类。输尿管本身又分为腔内梗阻，以及输尿管壁障碍所致两大类。结石为腔内梗阻最常见原因，可发生在输尿管任何一处但以自然转折或狭窄处最多，也可在肾内的小管腔内。肾内结石多由代谢障碍疾病引起，常见于尿酸结晶或服用可溶性较差的磺胺药等。多发性骨髓瘤中部分病例中含有大量本-周蛋白可以沉着于肾小管造成阻塞。部分肾乳头坏死病例坏死的组织可以脱落造成梗阻。此外泌尿系统出血形成血块也可能阻塞尿路，后两者情况大多在肾外为主。

　　膀胱功能障碍导致尿路梗阻的原因大多为神经源性，可因先天性肌肉发育不全或脊髓功能障碍等引起。后天性常见于糖尿病、脑血管病变、多发性硬化症或帕金森病等。由解剖性病变造成输尿管壁病变包括炎症、肿瘤等所造成的狭窄。尿路以外造成梗阻常因生殖系统、胃肠系统，以及血管或后腹膜其他病变引起。前列腺肥大或肿瘤常是男性发病的原因。女性则很多因子宫、卵巢等病变引起。克隆氏病或胃肠其他肿瘤可以压迫输尿管而导致梗阻。腹膜后病变可因炎症、肿瘤（原发或转移等）引起。

　　引起梗阻性肾病的原因很多，其分类的方法亦有多种，其常见并发症有感染、尿潴留、血尿、肾功能不全等。

　　1、感染

　　泌尿系统梗阻最危险的是有细菌的尿可经过肾盏穹窿部裂隙进入血液，也可通过高度膨胀时变得极薄的泌尿系统上皮层进入血液，因此梗阻合并感染时，不仅感染难以控制，而且易发展为菌血症。

　　2. Hydronephrosis

　　Long-term obstruction of the kidney can lead to gradual deterioration of kidney function. In cases of complete obstruction of both kidneys or a solitary kidney, anuria may occur, leading to renal failure.

　　The symptoms of obstructive kidney disease include the following points:

　　1. Pain

　　The typical manifestation is renal colic, which can be persistent but often exacerbated in a paroxysmal manner and radiated to the perineum. However, in patients with chronic gradually developed obstructive kidney disease, pain may not be very prominent, and occasionally only manifested as lumbago or discomfort. The kidney volume can be significantly enlarged in obstructive kidney disease caused by acute reasons, but in chronic cases, due to the proliferation of a large number of fibrous tissue, the volume may not necessarily increase, and many cases may show atrophy of the kidney on the affected side.

　　2. Urinary disorders

　　Bilateral complete obstruction can cause anuria, but most patients with this disease do not have complete obstruction, so they often present with polyuria. In cases with continuous attacks, anuria may occur during attacks, and polyuria during the intermission. In cases of obstruction caused by infection, bladder irritation symptoms may occur. In cases caused by bladder neck obstruction (such as benign prostatic hyperplasia), urinary retention may occur.

　　3. Hypertension

　　It is quite common, and its mechanism can be due to excessive intratubular pressure or interstitial pressure, which promotes excessive renin secretion; or due to renal disorder of water and sodium regulation mechanism, leading to water and sodium retention and the occurrence of hypertension. Generally, hypertension caused by unilateral kidney disease is more renin-dependent, while that caused by bilateral lesions is more water and sodium-dependent. After the obstruction is relieved, hypertension can generally improve. However, if the lesion has been present for a long time, hypertension may sometimes persist for a long time.

　　4. Polycythemia

　　Mainly due to excessive secretion of erythropoietin caused by renal pelvis hydrops. After correcting the obstruction in surgical operation, the excessive hematocrit can decrease. However, in clinical practice, not many patients truly show typical symptoms of this disease.

　　5. Acidosis

　　Mainly because it affects the secretion of H+ by the renal tubules. Some cases may be accompanied by high blood potassium levels.

　　The incidence of obstructive kidney disease has increased significantly recently, accompanied by a series of symptoms. Patients with obstructive kidney disease, from early微量protein excretion rate, to edema, proteinuria, kidney function damage, and other continuous aggravation, to the end stage of uremia, the result is kidney transplantation or dialysis treatment. Therefore, in the early stage of obstructive kidney disease, regular, multi-faceted, and strict care should be carried out.

　　1. Change clothes frequently:Since infection is often a factor that triggers the recurrence of kidney disease, it is necessary to bathe frequently. Keep the child's skin clean to prevent infection.

　　2. Not suitable for entering public places:To maintain fresh indoor air, try to avoid public places such as cinemas and stores. It is also important to pay attention to weather changes and prevent colds.

　　3. It is not advisable to discontinue or reduce the dose arbitrarily:For the treatment of nephropathy, it is necessary to follow the doctor's guidance, gradually reduce the dose until discontinuation as the condition improves. Parents should urge their children to take the medicine on time and in the correct amount, and should not reduce or discontinue the medicine arbitrarily to avoid recurrence of the disease.

　　4. Pay attention to rest:Because children have poor self-discipline, love to play, and are easy to overwork and have insufficient sleep, it is especially important to limit the amount of activity, arrange the rest and work schedule reasonably, and try to get sufficient rest. Parents should limit the amount of activity.

　　Obstructive nephropathy refers to the obstruction of urine flow in the urinary tract, causing backward pressure, affecting the normal physiological function of the renal parenchyma, and leading to renal lesions. The following examinations need to be done:

　　1. Urinalysis

　　Urinalysis can vary depending on the cause. Most cases have proteinuria, but the amount is generally not much. Red and white blood cells can often be observed. For those caused by stones, tumors, and so on, there can be a lot of blood cells, and sometimes gross hematuria can occur. If there is a concurrent infection, there can be a lot of white blood cells. In cases caused by renal papillary necrosis, not only can there be a lot of red blood cells in the urine, but there are also a lot of white blood cells. At this time, the typical urine color is like 'meat washing water', and necrotic tissue can be seen after filtering through red gauze. Urinalysis can often suggest the cause, such as sulfonamide drugs, uric acid, and so on, and their special crystals can be attached to the casts. In cases with concurrent infection, the urine pH is often elevated, and if the pH value is above 7.5, it usually indicates that the obstruction has been for a long time, and the lesions have become chronic.

　　2. Ultrasound examination

　　In addition to measuring the size of the kidneys, it can also detect renal pelvis hydronephrosis, and many stones can also be detected. If the examination finds that there is still a lot of urine retained in the bladder after urination, it indicates the presence of benign prostatic hyperplasia, tumor, or neurogenic cause.

　　3. Abdominal X-ray film

　　Positive urinary tract stones can be detected, and calcification foci can be seen in the abdominal cavity and renal area for those caused by tuberculosis bacteria. At the same time, the size of the kidneys can also be roughly observed. CT can not only measure the size of the kidneys but also detect whether there is an expansion of the collecting duct system. The characteristic is that if caused by tumors (intra-or extrarenal), retroperitoneal lesions, and so on, it is more important for diagnosis. A small number of special cases may require retrograde ureterography. Some acute obstruction cases can help clarify the cause after intravenous pyelography.

　　The dietary principles for patients with obstructive nephropathy are mainly formulated based on their pathophysiological changes, with the general principles being:

　　1. For those with water and sodium retention and edema, the intake of water and sodium should be restricted, especially for those with heart failure or severe hypertension, who should strictly limit their intake and even adopt a salt-free diet. After the heart failure is corrected and blood pressure returns to normal, the original diet can be resumed.

　　2. Ensure sufficient calories, especially for children and adolescents in the growth and development stage. If limiting protein or sugar affects calorie intake, it may affect the growth and development of children and adolescents, leading to malnutrition and other changes. For patients with chronic renal failure, ensuring sufficient calories is particularly crucial. For patients with obesity and diabetic kidney disease, attention should be paid to controlling calorie intake.

　　3. Asymptomatic proteinuria or hematuria, or during the convalescence period of various kidney diseases, there is no need to restrict diet deliberately. It is only necessary to moderately reduce the intake of protein or salt. Patients with renal insufficiency should limit protein intake, reduce the intake of protein, such as poultry, seafood, and soy products, which is conducive to reducing the pressure on the kidneys, thereby protecting the kidneys. However, protein intake should not be reduced too much or lead to malnutrition. Nutritionists often consider and suggest the proportion of food intake for patients.

　　The treatment of obstructive nephropathy mainly includes the following points:

　　1. Remove life-threatening diseases

　　(1) Gram-negative sepsis: When fever occurs with severe or complete obstruction and pyelonephritis, blood and urine bacterial cultures, colony counts, and drug sensitivity tests should be performed, and strong antibiotics should be used for active anti-infection treatment.

　　(2) Acute renal papillary necrosis: Often caused by pyelonephritis complicating obstruction, in which case the renal tissue can be rapidly destroyed, leading to acute renal failure. Immediate measures should be taken, and emergency surgery to relieve obstruction may be necessary if required.

　　(3) Acute or chronic renal failure: When hyperkalemia, acidosis, convulsions, coma, or pericarditis occur, it is necessary to first perform hemodialysis to maintain life and then take measures to remove the obstruction.

　　(4) Diuretic after obstruction: When serious electrolyte imbalance, fluid volume reduction, and hypotension occur, it is necessary to correct them urgently.

　　2. Resolve obstructions and treat complications to protect renal function

　　Take all necessary measures to prevent renal function deterioration and restore renal function. Surgical operations reduce intrarenal pressure and correct anatomical structural abnormalities; control urinary tract infections, treat other complications such as hypertension; carefully follow up the recurrence of obstruction and take preventive measures, which are all important measures for protecting renal function.

　　3. Clarify the cause of obstruction and provide special treatment

　　Remove obstructions and keep the urinary tract unobstructed by using methods such as cystoscopy, nephrotomy, pyelotomy, percutaneous ureteral surgery, and suprapubic cystotomy. When it is not possible to remove the cause of obstruction, urine flow is transferred through ureterointestinal anastomosis. Sometimes, nephrectomy for obstruction may need to be considered.