SEMINAR PRESENTATION - PATHOLOGY REF: ROBBINS

1. Chronic pyelonephritis
-LAYA K PILLAI

2. ▪ 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

3. 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

4. Based on the cause, it is of 2 types
▪ CHRONIC OBSTRUCTIVE PYELONEPHRITIS
▪ REFLUX NEPHROPATHY (chronic reflux-associated pyelonephritis)

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

6. 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.

7. 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 SOTHAT
URINE IS FORCED INTOTUBULES
DAMAGE OF KIDNEY AND SCAR FORMATION

9. Morphology of CP
Gross:
▪ 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 deformities
M/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

11. 40X 10X

12. Tubular atrophy
with thyroidization

13. Predisposing factors
Factors 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

14. CLINICAL FEATURES
▪ May present with fever, flank pain
▪ Usually present with chronic renal failure or symptoms of hypertension
▪ frequency of micturition & dysuria

15. COMPLICATIONS
▪ Proteinuria
▪ Focal glomerulosclerosis
▪ Progressive renal scarring leading to end-stage renal disease
▪ Papillary necrosis
▪ Perinephric abscess

16. DIAGNOSIS
• Urinalysis
• Intravenous pyelography
• ultrasound

17. 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.

18. • FLUID INTAKE
• CRANBERRY JUICE
• PAIN MANAGEMENT

19. VARIANT OF CP
▪ xanthogranulomatous pyelonephritis (XGP)
▪ emphysematous pyelonephritis (EPN) due to diabetes mellitus

20. 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

21. 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

22. CLINICAL FEATURES
• Persistent sterile pyouria
• Microscopic haematuria
DIAGNOSTICTEST
• Identification of M. tuberculosis by repeated culture of urine on LJ
media

23. THANKYOU
#PRAYFORPARIS