PYELONEPHRITIS

1. PYELONEPHRITIS Dr Kiran H S Assistant professor YMC, Pathology

4. TUBULOINTERSTITIAL NEPHRITIS • Tubules + Interstitium predominantly • 1% of the autopsy kidneys • Interstitium – Mononuclears + Eosinophils + Edema • Requires clinico-pathological correlation

5. TUBULOINTERSTITIAL NEPHRITIS CAUSES: • Infections • Acute Bacterial pyelonephritis • Chronic pyelonephritis (including reflux nephropathy) • Other Infections (Viruses, Parasites)

6. TUBULOINTERSTITIAL NEPHRITIS CAUSES: 2. Toxins • Drugs • Acute hypersensitivity interstitial nephritis • Analgesic nephropathy • Heavy metals: Lead, Cadmium

7. TUBULOINTERSTITIAL NEPHRITIS CAUSES: 3. Metabolic Diseases • Urate nephropathy • Nephrocalcinosis • Hypokalemic nephropathy • Oxalate nephropathy

8. TUBULOINTERSTITIAL NEPHRITIS CAUSES: 4. Physical Factors • Chronic Urinary Tract Obstruction • Radiation nephropathy 5. Neoplasms Multiple myeloma

9. TUBULOINTERSTITIAL NEPHRITIS CAUSES: 6. Immunologic Reactions • Transplant Rejection • Sjogren syndrome • Sarcoidosis

10. TUBULOINTERSTITIAL NEPHRITIS CAUSES: 7. Vascular Diseases 8. Miscellaneous • Balkan nephropathy • Nephronophthisis-medullary cystic disease • “Idiopathic” Interstitial nephritis

11. Pyelonephritis And Urinary Tract Infection

12. Affects : Tubules Interstitium Renal pelvis TYPES: Acute Chronic Pyelonephritis & Urinary Tract Infection

14. Etiology & Pathogenesis • CAUSATIVE ORGANISMS • Gram negative bacilli > 85% • Escherichia coli • Proteus • Klebsiella • Enterobacter • Streptococcus faecalis • Staphylococci • Others

15. Etiology & Pathogenesis • Immune compromised (with transplants) • Polyoma virus • Cytomegalovirus • Adenovirus

16. SOURCES & ROUTE OF RENAL INFECTION • Ascending infection • Hematogenous route UTI: ENDOGENOUS INFECTION (PATIENT’S OWN FAECAL FLORA)

17. Pathways of Renal Infection • ASCENDING INFECTION: • Colonisation of distal • urethra & introitus • - Adhesins (pili),

18. Pathways of Renal Infection ASCENDING INFECTION 2. Common in females: - Short urethra, - Lack of defensive fluids - Hormonal changes – adhesion - Urethral trauma

19. Pathways of Renal Infection ASCENDING INFECTION 3. Multiplication in bladder: - Outflow obstruction, - Bladder dysfunction Residual volume of urine (Bacterial Growth)

20. Pathways of Renal Infection ASCENDING INFECTION 4. Vesicoureteral Reflux -Incompetence of vesicoureteral valve - Congenital/acquired

21. Pathways of Renal Infection ASCENDING INFECTION 5. Intrarenal Reflux - Most common at the poles of kidney

22. Pathways of Renal Infection • HAEMATOGENOUS ROUTE • Septicemia • Infective endocarditis • Ureteral obstruction • Debilitation • On immunosuppressive therapy • Non-enteric organisms

23. Vesicoureteral Junction

24. Voiding Cystourethrogram --- Vesicoureteral Reflux (30% of children)

25. Acute Pyelonephritis Acute suppurative inflammation of the kidney. • MORPHOLOGY • Gross- • Unilateral /bilateral • Focal abscess • Pelvis & Calyces- hyperemic and covered by purulent exudate.

26. MICROSCOPY: • Patchy interstitial suppurative inflammation, • Intratubular aggregates of Neutrophils, • Tubular necrosis; • Irregular distribution (poles common)

27. Acute Pyelonephritis

28. Ac. Pyelonephritis – Multiple abscesses

29. Ac. Pyelonephritis - Neutrophilic infiltration

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

31. Urinary findings • Microscopy: - Pus cells: pyuria - WBC casts. Culture and sensitivity.

32. Acute Pyelonephritis – Clinical Course • Sudden onset • Pain – costovertebral angle, • Fever and malaise, • Dysuria, frequency, urgency, • Pyuria, leucocytic casts, • Quantitative urine culture • Septicemic episodes • Papillary necrosis – ARF, • Allografts – polyoma virus infections;

33. Acute Pyelonephritis COMPLICATIONS: 1) Papillary necrosis … Diabetes mellitus, … UT obstruction … c/s: grey white-yellow necrosis … Microscopy- Coagulative necrosis

34. 2) Pyonephrosis- Accumulation of pus within the renal pelvis, calyces and ureter; kidney distended with pus. … Complete obstruction 3) Perinephric abscess … Extension through the renal capsule

35. Acute Pyelonephritis – Clinical Course • Uncomplicated cases with appropriate antibiotic treatment recovery is complete;

36. Chronic PyelonephritisAnd Reflux Nephropathy

37. Chronic pyelonephritis • Chronic tubulointerstitial renal disorder in which interstitial inflammation is associated renal scarring and pelvicalyceal damage. • Important cause of ESRD • TYPES OF CHRONIC PYELONEPHRITIS: • Chronic Reflux-associated(Reflux nephropathy) • Chronic Obstructive

38. Reflux nephropathy • Common in childhood • UTI + congenital vesicoureteral reflux + intrarenal reflux • Unilateral or bilateral • Chronic renal insufficiency • Sterile reflux - no infection;

39. Chronic obstructive pyelonephritis • Infection + obstructive lesions • Recurrent bouts of renal inflammation , parenchymal atrophy and scarring • Bilateral – posterior urethral valve, • Unilateral - urolithiasis, ureteric anomalies;

40. Chronic obstructive pyelonephritis MORPHOLOGY: • Asymmetric • Kidney- reduced in size due to irregular scars • Scars- upper and lower poles; coarse and well defined. • Calyces and renal pelvis- thickened & irregular. • Cortico-medullary scar overlying the dilated, blunted or deformed calyx. • Papillae are flattened.

42. Chronic Pyelonephritis

43. Chronic • Pyelonephritis: • Coarse polar • scars with • underlying • Blunted calyces

44. Chronic pyelonephritis - microscopy • Tubular atrophy • Dilated tubules filled with colloid casts (Thyroidisation) • Interstitial inflammation and fibrosis, • Hyaline arteriosclerosis if hypertension is present • Periglomerular fibrosis

46. Chronic Pyelonephritis

47. Chronic Pyelonephritis

48. Xanthogranulomatous variant – - C/S: yellowish orange nodules - foamy macrophages, plasma Cells, lymphocytes, neutrophils, giant cells - proteus infection + obstruction;

49. Xanthogranulomatous Pyelonephritis

50. Chronic pyelonephritis – clinical course • Insidious onset, • Acute recurrent pyelonephritis • Back pain • Fever, • Pyuria, bacteriuria; • Reflux – silent onset, • Polyuria and nocturia (loss of tubular function), • May show Focal Segmental Glomerulosclerosis;