Renal Abscess ,Xanthogranulomatous Pyelonephritis and Renal Tuberculosis

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In this update we focus on Dx and Mgt. of 3 challenging manifestations of renal infection Renal abscess ,Xanthogranulomatous pyelonephtitis and Renal TuberculosisSymptoms ,laboratory studies and imaging findings are non specificDiagnostic and therapeutic arsenals reduce the associated significant morbidity and mortality we will discuss pathophysiology ,diagnostic capabilities and treatment options applicable to those patients

Transcript of Renal Abscess ,Xanthogranulomatous Pyelonephritis and Renal Tuberculosis

  • Renal abscess ,Xanthogranulomatous pyelonephtitis and Renal TuberculosisAUA Update series 2014 ,Volume 33 ,Lesson 36Pais ,sharmma ,Pattison et al

    Anas Hindawi PGY3 Urology ResidentMakassed General HospitalBeirut Arab University

  • IntrodutionRetroperitoneal abscesses may arise from pathology originating sources most commonly the kidney

    Kidney infections itself span a wide spectrum like acute uncomplicated acute pyelonephritis

    Pyonephrosis ,Emphysematous Pyelonephritis pose true urologic emergencies

  • In this update we focus on Dx and Mgt. of 3 challenging manifestations of renal infection

    Renal abscess ,Xanthogranulomatous pyelonephtitis and Renal Tuberculosis

    Symptoms ,laboratory studies and imaging findings are non specific

    Diagnostic and therapeutic arsenals reduce the associated significant morbidity and mortality

    we will discuss pathophysiology ,diagnostic capabilities and treatment options applicable to those patients

  • Renal and Perinephric abscesses Renal abscesses are collections of pus within renal parenchyma ,further categorized by anatomical location

    Perinephric abscess extend beyond capsule but contained by Gerota fascia ,commonly caused by rupture of renal abscess thru. Renal capsule , seeding of Perinephric Haematoma or Urinoma

    An abscess extending through Gerota classified as Paranephric abscesses that may result from GI infectious process

  • Renal and Perinephric abscesses are reviewed together under the designation of renal abscess

    Paranephric abscesses are beyond preview in this update

  • EpidemiologyRelatively uncommon (0.01% hosp. admissions)

    Most often unilateral

    No gender predilection

    Prevalence increases with age

    Etiologies include infected renal or ureteral stones ,non calculus renal obstruction (*) ,pyelonephritis ,UTI ,previous urological surgeries ,PCKD

  • Predisposing factors include : DM , steroids ,HIV ,IV drug abuse ,prior uncomplicated UTI ,liver disease ,pregnancy

    15 % of abscesses occurred in patients without known predisposing factors

    DM represents an important factor acc. To a population based study in which hazard ratio of hospitalization of 3.81 in DM patients was seen

    DM was associated with lengthened hospitalization with no increase in mortality

  • PathogenesisThe advent use of antibiotics had led to earlier control and reduced hameatogenous spread of pyogenic G+ve infections shifting isolates to G-ve rods

    Mot common organisms cultured are : E.coli ,Klebsiella ,Proteus ,Pseudomonas and staph. Aureus

    It is suspected that Uropathogenic G-ve renal abscesses arise from ascending infection

    Rarely renal abscesses reported to arise from ascending infection tracking up fascial planes from prostate abscess or s/p biopsy

  • PresentationClassic presentation of fever and unilateral flank pain in 23%

    Common symptoms : Flank or abdominal pain ,palpable flank mass and voiding dysfunction

    Insidious onset of chills ,N/V and weakness of less than one week duration

    Laboratory findings of leulocytosis 90% ,pyuria 70%

  • Diagnosis Historically high degree of morbidity and mortality was referred to difficult diagnosis and delayed targeted treatment

    Recently CT replaced x-ray and execratory urogram ,it provides anatomical and adequate assessment of infectionNon contrast CT findings of fluid filled lesion (0-40 HU) with or without gas ,Contrast enhanced films showed peripheral thickening and enhancement

    Perirenal fluid and inflammatory stranding with thickened Gerota might present

  • CT is diagnostic in 90%

    Ultrasound is particularly useful in :children ,pregnant ,patient preference ,following known abscess

    Nonetheless Ultrasound sensitivity is much lower than CT in initial evaluation

    Ultrasound findings are variable :hypoechoic ,hyperechoic , complex cystic or post. Acoustic enhancement

    Doppler distinguish abscess from neoplastic lesion

  • Acute pyelonephritis is among the most common admission misdiagnoses

    Typically diagnosis is made clinically and treated non surgically

    Renal abscess distinguished from acute pyelonephritis by 2 features : 1) symptomatic > 5 days 2) fever > 5 days

    Not all acute pyelonephritis pts. Needs imaging ,unless high suspicion of obstruction or dowentrending of fever curve does not follow conservative and IV antibiotics management

  • TreatmentEmpiric ABx therapy should cover the most common uropathogen /E-coli ,klebsiella ,proteus and less commonly haematogenous spread staph-aureus/

    Culture data of abscess ,urine and blood has to be interpreted and considered

    Concordance of abscess and urine cultures may be observed in 49%

    Additional isolates might be seen in abscess but not vice-versa in urine

  • Small renal abscesses treated by IV ABx has to be observed for clinical improvement and changing of the course based on culture data

    Selection of initial treatment modality depends on : size ,location of abscess ,overall clinical status

    Efficacy of ABx therapy has been observed in smaller abscesses in immunocompetent patients

    Reports/siegel et al ,dall palma et al ,comploj et al / of abscesses resolution smaller than 5 cm , solitary or multiple using broad spectrum ABx over 6 weeks in some of the reports

  • Patients with no clinical improvement should be offered a drainage procedure

    ABx without drainage is not recommended in gravely ill immunocompromised pts

    Abscesses > 3cm in immunocompromised pts regardless the size not responding to ABx alone require drainage in combination with culture directed ABx

    Ultrasound and CT guided drainage allow excellent targeting and confirmation of appropriate drain placement

  • Yen et al reported 76% resolution rate of intrarenal/perinephric abscesses treated by percutaneous drainage with no description of the size

    Siegel et al reported 92% resolution rate for 3-5 cm intrarenal/perinephric abscesses with percutaneous drainage

    This approach proved to be useful even in >10 cm abscesses

    Meng et al reported successful approach in 7/11 abscesses with average size 11 cm ,all >5 cm

  • Patients had longer hospitalization ,multiple drain manipulations ,prolonged catheter placement

    Siegel et al reports a high failure rate of larger abscesses

    Loculations do not appear to be a contraindication

    Open surgical approach may be considered in suspected GI involvement ,large complex or multiloculated collections ,non functioning kidney

    Nephrostomy tube or uretral stent should be performed in the setting of obstruction and infection

  • Follow upProgress should be monitored to confirm clinical improvement

    Imagings /CT ,ultrasound/ are recommended to confirm resolution of abscesses

    There are no evidence based protocols to direct a course of follow up imaging

  • Xanthogranulomatous pyelonephritisXGP is a chronic inflammatory condition of the kidney distinguised by replacement of the renal parenchyma with granulomatous collections of lipid laden histocytes

    XGP is associated with chronic infection and obstruction leading to enlarged poorly or non functioning kidney

    Might mimic any other urological condition

    CT & MRI might show neoplastic process changes

  • Epidemiology XGP is identified in 8.2-19% of biopsies or nephrectomies performed for chronic pyelonephritis

    Annual incidence not sufficiently reported 1.4/100.000

    5th to 6th decades age average ,3/1 female to male

    Predisposition factors : UTI ,nephrolithiasis

    Diabetes as frequent co morbidity

  • PathophysiologyXGP most commonly encountered with chronic renal infection ,nephrolithiasis and obstruction

    Definitive correlation is poor for renal ischaemia ,lymphatic and venous obstruction ,impaired immune response and altered lipid metabolism a causative factor

    Concomitant infection with obstruction reported in significant numbers

    Nephrolithiasis is present in 82%

  • Urine cultures reveal G-ve uropathogens ,indicating ascending infection

    Proteus and E-coli are the most common offending agents

    Pseudomonas ,staphylococcus ,klebsiella , candida and anaerobs are reported

    In light of frequently associated upper tract obstruction ,urine cultures can be negative in up to 40% and when positive discordant

  • Presentation Several months symptoms are common

    Constitutional symptoms of weight loss ,malaise ,fever

    Examination may reveal tender palpable mass ,unilateral CVA tenderness 72%

    Findings indicating fistulization or local spread such as a draining flank sinus or empyema

    Leukocytosis ,elev. ESR and anemia ,liver dysfunction might present and reolve by Tx

  • DiagnosisClinically ,radiologically and histologically non specific features confused with renal cell carcinoma ,malacoplakia ,renal TB ,renal infarction ,pyonephrosis and wilms tumor Radiographic findings of classic non functioning enlarged kidney ,nephrolithiasis in up to 80%CT is the optimal modality for imaging and diagnosing XGP CT findings suggests presence of diffuse XGP are : poorly defined renal pelvis ,diminished renal pelvis fat ,hypoechoic non enhancing spherical nodules ,rim like enhancement around the mass ,air in urinary tract 9.8% with no typical emphysematous pyelitis/pyelonephritis

  • US may reveal hydronephrosis , stone ,pyenephrosis evidenced by internal ehoes from pus or debris in renal pelvisFocal form most commonly confused with tumors and abscesses ,with no reliable findings to differentiateMRI of