pyelonephritis csbrp

TUBULOINTERSTITIAL NEPHRITIS

Dr.CSBR.Prasad, MD.,Dr.CSBR.Prasad, MD.,

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

Tubules + Interstitium predominantlyTubules + Interstitium predominantly1% of the autopsy kidneys1% of the autopsy kidneysInterstitium – Mononuclears Interstitium – Mononuclears

+ Eosinophils + Eosinophils + Edema+ Edema

Requires clinico-pathological correlationRequires clinico-pathological correlation

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:1.1. InfectionsInfections

Acute Bacterial pyelonephritisAcute Bacterial pyelonephritis Chronic pyelonephritisChronic pyelonephritis

(including reflux nephropathy)(including reflux nephropathy) Other Infections (Viruses, Parasites)Other Infections (Viruses, Parasites)

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:2. Toxins2. Toxins

DrugsDrugsAcute hypersensitivity interstitial Acute hypersensitivity interstitial

nephritisnephritisAnalgesic nephropathyAnalgesic nephropathyHeavy metals,Heavy metals,

Lead, CadmiumLead, Cadmium

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:3. Metabolic Diseases3. Metabolic Diseases

Urate nephropathyUrate nephropathyNephrocalcinosisNephrocalcinosisHypokalamic nephropathyHypokalamic nephropathyOxalate nephropathyOxalate nephropathy

Nephrocalcinosis:- Is it dystrocic or metastatic- Why is kidney a preferred site for calcification?

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:4. Physical Factors4. Physical Factors

Chronic Urinary Tract ObstructionChronic Urinary Tract ObstructionRadiation nephropathyRadiation nephropathy

5. Neoplasms5. NeoplasmsMultiple myelomaMultiple myeloma

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:6. Immunologic Reactions6. Immunologic Reactions

Transplant RejectionTransplant RejectionSjogren syndromeSjogren syndromeSarcoidosisSarcoidosis

TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS

CAUSES:CAUSES:7. Vascular Diseases7. Vascular Diseases8. Miscellaneous8. Miscellaneous

Balkan nephropathyBalkan nephropathyNephronophthisis-medullary cystic disease Nephronophthisis-medullary cystic disease ““Idiopathic” Interstitial nephritisIdiopathic” Interstitial nephritis

Pyelonephritis And Urinary Tract Infection

Affects :Affects :TubulesTubules Interstitium Interstitium Renal pelvisRenal pelvis

TYPES:TYPES:AcuteAcuteChronicChronic

Pyelonephritis & Urinary Tract InfectionPyelonephritis & Urinary Tract Infection

Etiology & PathogenesisEtiology & Pathogenesis

Gram negative bacilli > 85%Gram negative bacilli > 85%– Escherichia coliEscherichia coli– ProteusProteus– KlebsiellaKlebsiella– EnterobacterEnterobacter– Streptococcus faecalisStreptococcus faecalis– StaphylococciStaphylococci– OthersOthers

Etiology & PathogenesisEtiology & Pathogenesis

Immune compromised (with transplants)Immune compromised (with transplants)– Polyoma virusPolyoma virus– CytomegalovirusCytomegalovirus– AdenovirusAdenovirus

UTI: ENDOGENOUS INFECTION

(PATIENT’S OWN FAECAL FLORA)

Pathways of renal infectionPathways of renal infection

Hematogenous routeHematogenous routeAscending infectionAscending infection

Pathways of Renal Infection

HAEMATOGENOUS ROUTE•Septicemia•Infective endocarditis•Ureteral obstruction•Debilitation•On immunosuppressive therapy•Non-enteric organisms

Pathways of Renal Infection

ASCENDING INFECTION:1. Colonisation of distal urethra & introitus

- Adhesins (pili),

Pathways of Renal Infection

ASCENDING INFECTION2. Common in females:

- Short urethra,- Lack of defensive fluids- Hormonal changes –

adhesion- Urethral trauma – sexual intercourse;

Pathways of Renal Infection

ASCENDING INFECTION3. Multiplication in bladder:

- Outflow obstruction,- Bladder dysfunction

Residual volume of urine (Bacterial Growth)

Pathways of Renal Infection

ASCENDING INFECTION4. Vesicoureteral Reflux

Incompetence of vesicoureteral valve

Vesicoureteral Junction

Voiding Cystourethrogram

---Vesicoureteral Reflux(30% of children)

Acute Pyelonephritis

Ac. Pyelonephritis – Multiple abscesses

Ac. Pyelonephritis - Neutrophilic infiltration

Acute PyelonephritisAcute Pyelonephritis

Acute suppurative inflammation Acute suppurative inflammation of the kidney of the kidney

MORPHOLOGY•Patchy interstitial suppurative inflammation,•Intratubular Neutrophils,•Tubular necrosis;•Irregular distribution (poles common)

Acute PyelonephritisAcute Pyelonephritis

COMPLICATIONS:COMPLICATIONS:Papillary necrosisPapillary necrosis… … Diabetes mellitus,Diabetes mellitus,… … UT obstructionUT obstructionPyonephrosisPyonephrosis… … Complete obstructionComplete obstructionPerinephric abscessPerinephric abscess… … Extension through the renal capsuleExtension through the renal capsule

Acute PyelonephritisAcute Pyelonephritis – Clinical Course – Clinical Course

Predisposing conditions associationPredisposing conditions association- UT Obstruction,- UT Obstruction,- Instrumentation,- Instrumentation,- V-U reflux,- V-U reflux,- Pregnancy,- Pregnancy,- Patient’s age and sex,- Patient’s age and sex,- Preexisting renal lesions,- Preexisting renal lesions,- Diabetes mellitus,- Diabetes mellitus,- Immunosuppression or immunodeficiency;- Immunosuppression or immunodeficiency;

Acute PyelonephritisAcute Pyelonephritis – Clinical Course – Clinical Course

Sudden onsetSudden onsetPain – costovertebral angle,Pain – costovertebral angle,Fever and malaise,Fever and malaise,Dysuria, frequency, urgency,Dysuria, frequency, urgency,Pyuria, leucocytic casts,Pyuria, leucocytic casts,Quantitative urine cultureQuantitative urine cultureSepticemic episodesSepticemic episodesPapillary necrosis – ARF,Papillary necrosis – ARF,Allografts – polyoma virus infections;Allografts – polyoma virus infections;

Acute PyelonephritisAcute Pyelonephritis – Clinical Course – Clinical Course

Uncomplicated cases with Uncomplicated cases with appropriate antibiotic treatment appropriate antibiotic treatment recovery is complete;recovery is complete;

Chronic PyelonephritisAnd

Reflux Nephropathy

Chronic pyelonephritisChronic pyelonephritis

Chronic tubulointerstitial renal disorder in Chronic tubulointerstitial renal disorder in which interstitial inflammation is associated which interstitial inflammation is associated renal scarring and pelvicalyceal damage. renal scarring and pelvicalyceal damage.Important cause of ESKDImportant cause of ESKD

TYPES OF CHRONIC PYELONEPHRITIS:• Chronic Reflux-associated• Chronic Obstructive

Reflux nephropathyReflux nephropathy

Common in childhoodCommon in childhood

UTI + congenital vesicoureteral reflux + UTI + congenital vesicoureteral reflux + intrarenal refluxintrarenal reflux

Unilateral or bilateralUnilateral or bilateral

Chronic renal insufficiencyChronic renal insufficiency

Sterile reflux - no infection;Sterile reflux - no infection;

Chronic obstructive pyelonephritisChronic obstructive pyelonephritis

Infection + obstructive lesionsInfection + obstructive lesionsRecurrent bouts of renal inflammation and Recurrent bouts of renal inflammation and scarringscarringBilateral – posterior urethral valve,Bilateral – posterior urethral valve,Unilateral Unilateral

- urolithiasis, ureteric anomalies;- urolithiasis, ureteric anomalies;

Chronic obstructive pyelonephritisChronic obstructive pyelonephritis

MORPHOLOGY:MORPHOLOGY:Asymmetric, irregular scarring,Asymmetric, irregular scarring,Cortico-medullary scar overlying Cortico-medullary scar overlying the dilated, blunted or deformed the dilated, blunted or deformed calyxcalyx

Chronic Pyelonephritis

ChronicPyelonephritis:-Coarse polar scars with underlying-Blunted calyces

Chronic pyelonephritis - microscopyChronic pyelonephritis - microscopyTubular atrophyTubular atrophyDilated tubules filled with colloid casts Dilated tubules filled with colloid casts ((ThyroidisationThyroidisation))Interstitial inflammation and fibrosis,Interstitial inflammation and fibrosis,Hyaline arteriosclerosis if hypertension is Hyaline arteriosclerosis if hypertension is presentpresentPeriglomerular fibrosisPeriglomerular fibrosisXanthogranulomatousXanthogranulomatous variant – variant –

(foamy macrophages, plasma Cells, (foamy macrophages, plasma Cells, lymphocytes, neutrophils, giant cells)lymphocytes, neutrophils, giant cells)

-- -- proteusproteus infection + obstruction; infection + obstruction;

Chronic Pyelonephritis

Chronic Pyelonephritis

Chronic pyelonephritisChronic pyelonephritis – – clinical courseclinical course

Insidious onset,Insidious onset,Acute recurrent pyelonephritisAcute recurrent pyelonephritisBack painBack painFever,Fever,Pyuria, bacteriuria;Pyuria, bacteriuria;Reflux – silent onset,Reflux – silent onset,Polyuria and nocturia (loss of tubular function),Polyuria and nocturia (loss of tubular function),May show Focal Segmental Glomerulosclerosis;May show Focal Segmental Glomerulosclerosis;

Analgesic Nephropathy

OBSTRUCTIVE LESIONSOF THE URINARY TRACT

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