Chronic pyelonephritis-LAYA K PILLAI

▪ Chronic inflammation of the renal tubules and interstitium with scarring and deformity of the renal calyces and pelvis

▪ Occurs due recurrent attacks of inflammation and scarring

▪ It’s the commonest cause of end stage renal disease (ESRD)

▪ Nephron loss

Introduction

Affects whom??

▪ more often in infants and young children

▪ Children with congenital anomalies of urogenital system

▪ Person with flaccid bladder due to spinal cord injury

Based on the cause, it is of 2 types

▪ CHRONIC OBSTRUCTIVE PYELONEPHRITIS

▪ REFLUX NEPHROPATHY (chronic reflux-associated pyelonephritis)

CHRONIC OBSTRUCTIVE PYELONEPHRITIS

Obstruction to outflow of urine @ diff levels predisposes the kidney to infectionRecurrent episodes of such obstruction and infection result in renal damage and scarring Rarely recurrent attacks of acute pyelonephritis can lead to renal damageIt can be B/L, as with congenital anomalies of urethra (posterior urethral valve)Or it can be U/L, as with calculi or tumors

Reflux nephropathy

▪ Commonest cause of chronic pyelonephritis▪ Results from superimposition of UTI on congenital

vesicoureteral reflux (VUR) and intrarenal reflux▪ reflux of urine up into ureters during micturition▪ Manifests in early childhood .The incidence of reflux according

to sex is equal in infancy, but after infancy both pyelonephritic scarring and reflux are far more common in females. Infection is the likely cause of progressive scarring in females.

CONGENITAL ABSENCE OR SHORTENING OF INTRAVESICAL PORTION OF URETER

URETER NOT COMPRESSED DURING MICTURITION

REFLUX OF URINE INTO URETERS

REFLUX RESULTS IN INCREASE IN PRESSURE IN PELVIS SO THAT URINE IS FORCED INTO TUBULES

DAMAGE OF KIDNEY AND SCAR FORMATION

Morphology of CPGross: ▪ Uneven scarring of kidneys unlike symmetrical as in the case of chr. GN▪ Hallmark : scarring involvement in pelvis or calyces or both leading to papillary

blunting and marked calyceal deformitiesM/E:▪ Uneven interstitial fibrosis▪ inflammatory infiltrate of lymphocytes and plasma cells▪ Dilation or contraction of tubules with atrophy of lining epithelium▪ Sclerosis of glomeruli▪ Tubules may contain pink to blue glassy appearing PAS-positive casts known as colloid

casts that suggest appearance of thyroid tissue hence descriptively called thyroidization

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Tubular atrophy with thyroidization

Predisposing factorsFactors that may affect the pathogenesis of chronic pyelonephritis are as follows:▪ (1) the sex of the patient and his or her sexual activity;▪ (2) pregnancy, which may lead to progression of renal injury with loss of renal function;▪ (3) genetic factors;▪ (4) chronic bladder infections ▪ (5) neurogenic bladder dysfunction. paralysis from spinal cord injury, or tumors▪ (6) Catheters, tubes, or surgical procedures may also trigger a kidney infection.

In cases with obstruction, the kidney may become filled with abscess cavities 

CLINICAL FEATURES

▪ May present with fever, flank pain

▪ Usually present with chronic renal failure or symptoms of hypertension

▪ frequency of micturition & dysuria

COMPLICATIONS

▪ Proteinuria▪ Focal glomerulosclerosis▪ Progressive renal scarring leading to end-stage renal

disease▪ Papillary necrosis ▪ Perinephric abscess

DIAGNOSIS

• Urinalysis• Intravenous pyelography• ultrasound

TREATMENT

▪ Antibiotic therapy▪ Relieve obstruction▪ Analgesics ▪ The role of surgical correction of

vesicoureteric reflux remains uncertain, but meticulous control of infection appears to prevent progressive scarring.

•FLUID INTAKE•CRANBERRY JUICE•PAIN MANAGEMENT

VARIANT OF CP

▪  xanthogranulomatous pyelonephritis (XGP) ▪ emphysematous pyelonephritis (EPN) due to diabetes

mellitus

TUBERCULOUS PYELONEPHRITIS

• Tuberculosis of kidney occurs due to haematogenous spread of infection from another site, most often from lungs.

• Less commonly from ascending infection from the tuberculosis of genitourinary system such as from epididymis or fallopian tube.

• The renal lesions in tuberculosis may be in the form of 1.tuberculous pyelonephritis or 2.multiple miliary tubercles

Morphological features

GROSS:• Bilateral• Usually involving medulla with replacement of the

papillae by caseous tissue• Huge number of small scattered granulomas seen

M/E:• Typical caseating epitheloid cell granulomatous

reaction is seen• Afb can be demonstrated

CLINICAL FEATURES

• Persistent sterile pyouria• Microscopic haematuria

DIAGNOSTIC TEST

• Identification of M. tuberculosis by repeated culture of urine on LJ media

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