pyelonephritis csbrp
TRANSCRIPT
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TUBULOINTERSTITIAL NEPHRITIS
Dr.CSBR.Prasad, MD.,Dr.CSBR.Prasad, MD.,
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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
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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)
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TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS
CAUSES:CAUSES:2. Toxins2. Toxins
DrugsDrugsAcute hypersensitivity interstitial Acute hypersensitivity interstitial
nephritisnephritisAnalgesic nephropathyAnalgesic nephropathyHeavy metals,Heavy metals,
Lead, CadmiumLead, Cadmium
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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?
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TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS
CAUSES:CAUSES:4. Physical Factors4. Physical Factors
Chronic Urinary Tract ObstructionChronic Urinary Tract ObstructionRadiation nephropathyRadiation nephropathy
5. Neoplasms5. NeoplasmsMultiple myelomaMultiple myeloma
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TUBULOINTERSTITIAL NEPHRITISTUBULOINTERSTITIAL NEPHRITIS
CAUSES:CAUSES:6. Immunologic Reactions6. Immunologic Reactions
Transplant RejectionTransplant RejectionSjogren syndromeSjogren syndromeSarcoidosisSarcoidosis
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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
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Pyelonephritis And Urinary Tract Infection
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Affects :Affects :TubulesTubules Interstitium Interstitium Renal pelvisRenal pelvis
TYPES:TYPES:AcuteAcuteChronicChronic
Pyelonephritis & Urinary Tract InfectionPyelonephritis & Urinary Tract Infection
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Etiology & PathogenesisEtiology & Pathogenesis
Gram negative bacilli > 85%Gram negative bacilli > 85%– Escherichia coliEscherichia coli– ProteusProteus– KlebsiellaKlebsiella– EnterobacterEnterobacter– Streptococcus faecalisStreptococcus faecalis– StaphylococciStaphylococci– OthersOthers
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Etiology & PathogenesisEtiology & Pathogenesis
Immune compromised (with transplants)Immune compromised (with transplants)– Polyoma virusPolyoma virus– CytomegalovirusCytomegalovirus– AdenovirusAdenovirus
UTI: ENDOGENOUS INFECTION
(PATIENT’S OWN FAECAL FLORA)
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Pathways of renal infectionPathways of renal infection
Hematogenous routeHematogenous routeAscending infectionAscending infection
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Pathways of Renal Infection
HAEMATOGENOUS ROUTE•Septicemia•Infective endocarditis•Ureteral obstruction•Debilitation•On immunosuppressive therapy•Non-enteric organisms
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Pathways of Renal Infection
ASCENDING INFECTION:1. Colonisation of distal urethra & introitus
- Adhesins (pili),
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Pathways of Renal Infection
ASCENDING INFECTION2. Common in females:
- Short urethra,- Lack of defensive fluids- Hormonal changes –
adhesion- Urethral trauma – sexual intercourse;
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Pathways of Renal Infection
ASCENDING INFECTION3. Multiplication in bladder:
- Outflow obstruction,- Bladder dysfunction
Residual volume of urine (Bacterial Growth)
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Pathways of Renal Infection
ASCENDING INFECTION4. Vesicoureteral Reflux
Incompetence of vesicoureteral valve
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Vesicoureteral Junction
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Voiding Cystourethrogram
---Vesicoureteral Reflux(30% of children)
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Acute Pyelonephritis
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Ac. Pyelonephritis – Multiple abscesses
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Ac. Pyelonephritis - Neutrophilic infiltration
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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)
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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
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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;
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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;
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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;
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Chronic PyelonephritisAnd
Reflux Nephropathy
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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
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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;
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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;
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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
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Chronic Pyelonephritis
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ChronicPyelonephritis:-Coarse polar scars with underlying-Blunted calyces
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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;
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Chronic Pyelonephritis
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Chronic Pyelonephritis
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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;
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Analgesic Nephropathy
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OBSTRUCTIVE LESIONSOF THE URINARY TRACT
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