CHRONIC PYELONEPHRITIS ANDA · PDF filesuperimposed diffuse acute pyelonephritis but without...
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CHRONIC PYELONEPHRITIS AND ARTERIAL HYPERTENSION
By ALLAN M. BUTLER
(From the Department of Pediatrics of the Harvard Medical School and the Infants' andChildren's Hospitals, Boston)
(Received for publication July 7, 1937)
T'he present paper presents certain clinical andpathological evidence which demonstrates that hy-pertension not infrequently is associated withpyelonephritis before there is any appreciable dim-inution in renal function and that hypertensionwhich is secondary to unilateral pyelonephritismay disappear when the involved kidney is re-moved.
Ritter and Baehr (1) described renal arteriolarsclerosis in congenital polycystic disease of thekidney and remarked upon a preliminary periodof arterial hypertension, cardiac hypertrophy andhyposthenuria that usually precedes the terminaluremia in that disease. Bell and Pedersen (2)stated that " hypertension has never been reportedin pyelonephritis." Volhard (3) and Schwarz(4) reported hypertension-in patients with con-tracted kidneys (schrumpfnieren). Longcopeand Winkenwerder (5) reported elevated bloodpressures in the uremic phase of cases of chronicpyelonephritis. Weiss, Parker and Robb (6)observed that patients with malignant hyperten-sion frequently had a history of chronic pyelone-phritis, pyelitis, or perinephritic abscess. Theysuggested that such a renal infection may heal butthat the hypertension in'itiated by it may continueto progress. Fishberg (7) mentioned the hyper-tension that may occur in children in the presenceof urinary obstruction and in polycystic diseaseof the kidney when there is extensive destructionof renal parenfchyma. He stated, however, thathypertension does not occur in that disease if thereare extensive areas of intact parenchyma. Peters(8), Peters, Lavietes and Zimmerman (9), andZimmerman and Peters (10) have called attentionto the frequency with which pyuria and eclampsiaare associated in pregnancy and suggested a re-lation between urinary tract infection and hyper-tension. Kimmelstiel and Wilson (11) studiedthirteen patients with acute diffuse pyelonephritis;nine died in uremia, and hypertension was presentin four of these. Two patients presented what
was interpreted as essential hypertension withsuperimposed diffuse acute pyelonephritis butwithout renal insufficiency. Twenty-six patientswho suffered from diffuse chronic pyelonephritiswere also studied; of these, hypertension anduremia were associated in sixteen; hypertensionalone was present in four, and uremia withouthypertension in six. Hypertension withoutmarked renal insufficiency, therefore, was presentin six of their patients. In the majority of in-stances, they were unable to decide whether theywere dealing with a primary " vascular " hyper-tension or with a secondary " renal " hypertension.
In spite of the frequency with which pyelone-phritis is encountered in childhood (12), we havefound no report of a serious hypertension oc-curring in the pyelonephritis of childhood beforerenal insufficiency was present. Interestinglyenough, Amberg ( 13) in reporting twenty-fivecases of hypertension in children included fivepatients with pyuria or bacilluria but made no par-ticular comment upon the presence of pyelonephri-tis in these patients.The records concerning the blood pressures of
many of the patients admitted to this hospital withchronic pyelonephritis are not complete enough tosupply accurate information concerning the re-spective times at which the hypertension, if pres-ent, and renal insufficiency first appeared, but suchdata as are available seem significant. During thepast ten years fifteen children between three andeleven years of age were shown at necropsy tohave pyelonephritis. Adequate records of theblood pressures of seven of these patients are notavailable. The records of the blood pressures forthe remaining eight patients show systolic pres-sures ranging from 250 to 140 mm. Hg and dia-stolic pressures from 170 to 110 mm. Hg, theaverage systolic and diastolic pressures being re-spectively, 190 and 140 mm. Hg. Two of thesepatients (Cases 3 an'd 4 reported below) had hy-pertensive crises and died of cardiac failure before
ALLAN M. BUTLER
significant nitrogen retention occurred. The clini-cal histories of two others of the group studiedpathologically indicated that the pyelonephritisand hypertension preceded severe nitrogen reten-tion. During the same ten year period three pa-tients with pyelonephritis and hypertension diedand permission for autopsy was not obtained.The histories of two of these patients (Cases 1and 2 below) indicate that the pyelonephritis andhypertension preceded significant* renal insuffi-ciency and nitrogen retention. During this same
definite proof that the pyelonephritis preceded thehypertension.The fifth case reported here is that of a patient
who, coincident with a ureteral calculus, wasfound to have a unilateral pyelonephritis and dur-ing the course of the next 8 months developedhypertension and cardiac failure. The removal ofthe one infected kidney was followed by clearingof the urine and a return of the blood pressure tonormal where it has remained for 20 months.In this case there is strong evidence th-at the pye-
* 9'-Fi [' A#f s,I ts Mbiiz,
FIG. 1.PHOTOMICROGRAPH OF MICROSCOPIC SECTION PREPARED FROM KIDNEY.OF CASE 4
Hematoxylin and eosin. Reduced from a magnification of 240 di-ameters. Note prominence and thickening of walls of small arterioles,interstitial infiltration and casts in the renal tubules. Both chronic pyelo-nephritis and nephrosclerosis were present in the various sections examined.
period nine patients with pyelonephritis and hy-pertension were admitted to the hospital and whenlast seen were living. Of these patients only onehad renal insufficiency, and in this one the pyelo-nephritis and hypertension preceded the appear-ance of the diminished renal function.Thus we have fifteen patients (six dead and
nine living) who have had chronic pyelonephritisand hypertension over a period of years beforethere was appreciable diminution in kidney func-tion. The detailed records of four of these pa-tients are given below. In these cases there is no
lonephritis preceded the hypertension and in someway had a causal relation to it.
Subsequently, another patient, Case 6, who hada unilateral pyelonephritis and hypertension whichwas relieved by right nephrectomy, and whosehistory suggested a relation between the renallesion and hypertension, was seen on the pediatricward of the Massachusetts General Hospitalthrough the kindness of Dr. Harold Higgins andDr. J. D. Barney.'
1 A full report of this patient will be made by Dr.Barney. It is through his kindness that a brief descrip-tion is given with the cases reported here.
PYELONEPHRITIS AND HYPERTENSION
It is of particular interest in relation to the lasttwo patients that A/foritz (14) reported three pa-tients with essential hypertension in each of whomthe renal arteriolar sclerosis was found at ne-cropsy to be limited to one kidney.
Both chronic pyelonephritis and nephrosclerosiswere revealed by postmortem examinations per-formed on two of our patients (Cases 3 an'd 4).The photomicrograph shown in Figure 1 illus-trates the extensive character of the renal ar-teriolar sclerosis in Case 4. From the clinical ex-
tients who suffered from both pyelonephritis andhypertension.A detailed review of the clinical observations
concerning the association of pyelonephritis andhypertensioni in patients studied in this hospital,however, led to the hypothesis that the hyperten-sion might well be related to the local effect of thepyelonephritis rather than to the renal insuffici-ency encountered late in the disease. When thishypothesis was put to an empirical test by the re-moval of the infected kidney in a patient whosuffered from unilateral pyelonephritis and hyper-
FIG. 2. PHOTOMICROGRAPH OF MICROSCOPIC SECTION PREPARED FROM THEKIDNEY REMOVED FROM CASE 5
Hematoxylin and eosin. Reduced from a magnification of 240 di-ameters. Note diffuse pyelonephritis. No thickening of arterioles com-parable to that noted in Case 4 is demonstrable.
amination of the retinal and peripheral vessels itis proable that nephrosclerosis was present in ad-dition to the pyelonephritis in Cases 1 and 2. Itis clear that no conclusion may be drawn from ourevidence in these four cases concerning' the rela-tive time of onset of the pyelonephritis and thenephrosclerosis or their relative importance in theproduction of hypertension. The same difficultywas encountered by Kimmelstiel and Wilsoh ( 11)when they attempted to decide whether they weredealing with primary " vascular " hypertension orwith secondary " renal " hypertension in their pa-
tension (Case 5) it was found to be effective.The results in Dr. Barney's case (Case 6) lendfurther support to such a relation between thepyelonephritis and hypertension.
Pathological examination of the kidney re-moved from our patient, Case 5, showed in ad-dition' to severe pyelonephritis very early sclerosisof the renal arterioles. These vascular lesionswere not sufficiently advanced or prominent tomerit the term of nephrosclerosis as it is ordi-narily understood. The photomicropraph of Fig-ure 2 illustrates the absence in Case 5 of such a
ALLAN M. BUTLER
renal arteriolar sclerosis as observed in Case 4.It is well known that chronic inflammatory proc-esses of various kinds are accompanied by vas-cular changes in the involved areas. In consider-ing the r6le of ischemia and infections in the pro-duction of hypertension, it is of interest thatParker and Weiss (15) observed arteriolar sclero-sis in the lung in the presence of pulmonary con-gestion and infection. That obstruction to theflow of urine from one kidney may resu