CLINICAL-LABORATORY MARKERS OF FIBRILOGENESIS DISORDERS IN THE SEVERITY OF PYELONEPHRITIS IN CHILDREN

Aim of the research: to establish the role of undifferentiated connective tissue dysplasia, as a manifestation of violation of fibrillogenesis, in the severity of the course of pyelonephritis in children. 148 children with pyelonephritis from 3 to 18 years were examined. As a result of catamnestic surveillance, they were divided into 2 groups: I – 92 persons, children with chronic pyelonephritis in which were diagnosed 3 or more episodes of relapse of pyeloneOriginal Research Article: full paper (2018), «EUREKA: Health Sciences» Number 2

In practically all children with chronic pyelonephritis, the values of free and bound oxyproline fractions in blood plasma were significantly increased (47.14±0.03 μmol/l and 40.08±0.03 μmol/l, respectively), according to arithmetic meanings, reliably differing from the data of children with acute pyelonephritis (17.65±0.01 μmol/l and 17.22±0.02 μmol/l), in which these oxyproline fractions were elevated only in 12.0 % and 16.0 % of the subjects.
In 97.0 % of children with chronic pyelonephritis, the level of oxyproline in urine was elevated and significantly exceeded the level of excretion of oxyproline in urine in children with acute pyelonephritis. The presence of UCTD in a child plays an important role in the process of chronic pyelonephritis, and children with its manifestations have a heavier course of disease with frequent relapses, therefore, the presence of signs UCTD is prognostically unsuccessful, which dictates the need for the appointment of metabolic therapy in the first episodes of the disease in children, if they

Introduction
Diseases of the organs of the urinary system take one of the leading places in the structure of childhood diseases. According to statistics, their prevalence has increased over the years. The frequency of their low-symptomatic atypical prograding is increasing [1].
In recent years, not only in Ukraine, but also in the world, attention is focused on the increase in the frequency of diseases of the organs of the urinary system. At the same time, the structure of nephropathy in children is dominated by diseases of the congenital and hereditary genesis, as well as diseases associated with hereditary predisposition, with a latent onset and torpid flow [2]. Particular attention deserves children with manifestations of connective tissue dysplasia (CTD) [3].
Data from studies conducted in the European post-soviet area show the prevalence of undifferentiated connective tissue dysplasia (UCTD) from 9.0 % to 80.0 %, depending on the age, sex, ethnic and clinical groups of the study. At the same time, scientists are concerned about the progressive growth in the population of individuals with a displastic phenotype, which is considered as the result of the impact of new mutagenic factors of social, technological and environmental nature, which form an increase in the so-called "genetic cargo" [4,5]. The idea of "syndrome violation of gene homeostasis" were formulated, which may be the result of a mutation of one (monogenic theory), and several (polygenic theory) of genes [6,7]. The uniqueness of the structure and functions of the connective tissue creates conditions for the emergence of a large number of its anomalies and diseases caused by chromosomal and gene defects that have a certain type of inheritance or arise as a result of external mutagenic effects in the fetal period [8]. In addition to a large number of diseases, most often based on gene defects, birth defects of the connective tissue (CT) of multifactorial nature are often present today [9,10].
CTD are linked both to a violation of the synthesis of collagen and fibrilogenesis, as well as with changes in its biodegradation, fermentopathies, defects of fibronectin, elastin, glycoproteins, proteoglycans, and also with a deficiency of various cofactors of enzymes (magnesium, zinc, copper), ascorbic acid, oxygen and etc., which are involved in the formation of covalent bonds necessary to stabilize collagen structures, which are based on the mutations of genes encoding the synthesis and spatial organization of CT elements [6,11].

Medicine and Dentistry
In practice, it is more often encountered with undifferentiated forms of CTD -a genetically heterogeneous group of diseases of multifactorial nature with progressive flow, which are based on the violation of the synthesis, degradation or morphogenesis of the components of the extracellular matrix that occurs during the period of early embryogenesis or postnatal one under the influence of unfavorable environmental factors and can be manifested in different periods of life [12,13].
Kidneys take part in any pathological processes, since they are one of the main organs that support the homeostasis of the body at any age. Clinical manifestations of many diseases in children to a large extent depend on the degree of maturity of urinary organs and urination [14,15].
Taking into account the above remains an open question about the role of dysplasia of connective tissue (DCT) in pyelonephritis in children, the signs of which are increasingly encountered among patients nephrology and significantly affect the nature and course of the disease that causes the occurrence, chronicity and its resistance to therapy.

Aim of the research
To establish the role of undifferentiated connective tissue dysplasia, as a manifestation of violations of fibrilogenesis, in the severity of the course of pyelonephritis in children.

Materials and methods
148 children aged 3 to 18 years old underwent inpatient treatment with a diagnosis of pyelonephritis in the I pediatric department of the KZ LOR LODCL "OKHMATDYT" in 2016-2017. According to the results of the observation of patients in the catamnesis of the 1st and 3rd years, they were divided into 2 groups according to the severity of the disease and the frequency of episodes of exacerbation of the inflammatory process of the kidneys: group I (І-CP -92 persons)children with chronic pyelonephritis, in which there was a more severe course of the disease both in the debut and in the catamnesis, they were diagnosed with 3 or more episodes of pyelonephritis relapse throughout the year, the second group (II-AP -56 children) who had been diagnosed with acute pyelonephritis, was noticed a mild course of pyelonephritis in the debut of the disease during the year of catamnestic observation no relapse of the disease was noted.
The results of the study of the children of the main groups were compared with the results of a survey of healthy children -65 somatically healthy children of the same age (ІІІ-health-control), which were surveyed during the trips of a group of researchers in ecologically clean areas of Lviv region within the framework of the planned research work. All children were given a comprehensive clinical and laboratory examination in accordance with standard, commonly used in pediatric nephrology and pediatrics by clinical, laboratory and instrumental examinations [16].
When the children received next steps were done: -a thorough survey of children and their parents by a specially designed questionnaire to specify the necessary anamnestic data; -clinical examination of children and anthropometric measurements to determine the phenotypic signs of undifferentiated connective tissue dysplasia; -routine clinical, laboratory parameters (general blood test, general urine analysis, biochemical analysis of blood) and instrumental methods of examination (renal ultrasound, cystic cystography, excretory urography) were determined; -Brighton and modified criteria of Milkovskaya-Dimitrova and Karkasheva [17] deter-  [1,18] and free and bound fraction of oxyproline in blood serum using N. P. Sharaeva method [19].
The statistical processing of the research results was carried out using the Microsoft Excel program and the application package Statistica 5.0 for Windows. For the processing of the results that fell under the normal distribution, used the statistical method with the deduction of the arithmetic mean (M), standard deviation (SD). Calculations of the main statistical quantities were carried out according to generally accepted formulas [20].

Results of the research
In children of all observed groups, clinical and paraclinical manifestations of undifferentiated connective tissue dysplasia and violations of fibrillogenesis were investigated.
In children of the I group, complaints of frequent abdominal pain were noted in 52.17 % of cases, while in children of the II group only 32.14 % of the subjects (in control -7. In patients of all the observation groups, a history of life was collected, with an emphasis on the study of the frequency of antenatal and postnatal risk factors for the formation of the urinary system pathology and violations of fibrillogenesis ( Table 1). Table 1 The frequency of ante-and postnatal non-specific risk factors for the formation of pathology After children with pyelonephritis came, clinical manifestations and results of ultrasound examination of patients' kidneys were analyzed ( Table 2).
Clinical manifestations of general non-specific intoxication were registered in most children of the І group: pallor of the skin was noted in 1.5-2 times more often than in children of the ІІ group (52.0 % vs. 32.0 % of the children in the comparison group), periorbital cyanosis was noted 2 times more frequently in patients of the І group (43.0 % vs. 23.0 % of the children in the comparison group); signs of dysmetabolic nephropathy according to ultrasound data were also diagnosed 2.5 times more often in children of the main group (57.0 % against 20.0 % of children in the comparison group), ultrasound signs of inflammatory process of the kidneys met in 93.0 % of children of both group. Reliable difference in performance of muffled tones of the heart, dental enamel hypoplasia in children of observation group was not noted ( Table 2).
In order to study the possible role of undifferentiated connective tissue dysplasia as the causes of the more severe course of pyelonephritis in children and the propensity to chronize the process, as well as in order to predict frequent relapses of pyelonephritis in children, the nature and frequency of phenotypic manifestations of undifferentiated connective tissue dysplasia were analyzed ( Table 3).  In order to establish the possible role of undifferentiated dysplasia of connective tissue, as causes of more severe pyelonephritis in children and the propensity to chronize the process, as well as to predict frequent relapses of pyelonephritis in children, all children with pyelonephritis have been evaluated for the levels of oxyproline in plasma and urine as an indicator of increased collagen metabolism and a violation of fibrillogenesis. The obtained data were compared with the data of healthy children in the control group ( Table 4).
In order to study the processes of collagen degradation in children of both groups of observation, the level of oxyproline in urine as a measure of collagen metabolism and violation of fibrillogenesis was determined by the method of qualitative reaction (by degree of opacity) for all children. The results of excretion of oxyproline with daily urine in children of both groups of surveillance with pyelonephritis compared with the data of healthy children are presented in Table 5. Note: * -the probable difference between the data of children with pyelonephritis and healthy control groups p<0.01; ** -the probable difference between two groups of children with pyelonephritis p<0.01

Discussion
Comparison of the frequencies of ante-and postnatal non-specific risk factors for the formation of pathology showed that children with chronic pyelonephritis were significantly more likely to be on early artificial feeding in the first year of life (in the I group 52.17 % of children, in the comparison group -23.21 %, in control -0.14 %), were more likely to have acute respiratory diseases (in the I group -60.87 %, against 30.36 % of the children in the comparison group, in the control -0.12 %), the children of both groups were prone to atopy (8.1 % of children in the It group against 8.93 % of the children in the comparison group, in control -0.02 %). Mothers of children of the I group were significantly more likely to have anemia during pregnancy (almost 3 times: 61.96 % vs. 21.43 %, 0.08 % control) and 2 times more likely to have clinical manifestations of gestosis in the first half of pregnancy ( table 1).
The obtained data allow us to conclude that the frequency of nonspecific ante-and postnatal According to the literature in older children of the reference group, the level of free and bound oxyproline in the blood plasma is 12.2±0.49 μmol/l and 8.6±0.34 μmol/l, respectively. The higher the figure, the greater is collagen exchange [5].
In almost all of the examined children of both groups, the rates of increased collagen metabolism were significantly higher than healthy children ( Table 4) 2. In children with chronic pyelonephritis with frequent relapses, the frequency of almost all analyzed complaints was significantly and reliable higher than in children with acute pyelonephritis without relapses: frequent headaches -56.52 % vs. 25.0 % respectively), appetite loss -28.26 % vs. 19.64 %, frequent abdominal pain -52.17 % versus 32.14 %, increased fatigue -41.30 % versus 28.57 %.

4.
In almost all examined children with chronic pyelonephritis, the values of free and bound fractions of oxyproline in blood plasma (47.14±0.03 μmol/l and 40.08±0.03 μmol/l respectively) were significantly increased, for the mean arithmetic data significantly differ from the data of children with acute pyelonephritis (17.65±0.01 μmol/l and 17.22±0.02 μmol/l), in which these oxyproline fractions were elevated only in 12.0 % and 16.0 % examined, respectively, indicating an enhanced collagen exchange in children with chronic pyelonephritis. 5. Determination of the level of oxyproline in urine in children with chronic pyelonephritis testifies to increased decay and excretion of collagen metabolism products in a child's body in Medicine and Dentistry 97.0 % of the subjects, which significantly exceeds the level of excretion of oxyproline in urine in children with acute pyelonephritis, indicating the expressed disturbance of collagen catabolism in children prone to recurrence of pyelonephritis. 6. The presence of undifferentiated connective tissue dysplasia in the child plays an important role in the process of chronic pyelonephritis, and children with UCTD manifestations have a heavier course of disease with frequent relapses, therefore, the presence of signs of UCTD is prognostically unsuccessful, which dictates the need for appointment of metabolic therapy in the first episodes of the disease in children, if they have clinical and laboratory manifestations of UCTD.

Introduction
The main drugs for the treatment of sarcoidosis are glucocorticosteroids, their effectiveness has been proven in several randomized researches [1,2]. Despite the fact that corticosteroids remain the first-line drugs for most patients, cytostatics have been recognized as alternative drugs for the treatment of sarcoidosis. Methotrexate is the most commonly used cytotoxic drug,