PYELONEPHRITIS

DR. SHRADDHA KOIRALA

DEPARTMENT OF PATHOLOGY
NMCTH
 OBJECTIVES
• Definition
• Types
• Predisposing factors
 DEFINITION
• Pyelonephritis is a renal disorder affecting the
tubules, interstitium, and renal pelvis and is one of
the most common diseases of the kidney.
 TYPES
• Acute pyelonephritis
• Chronic pyelonephritis
 ACUTE PYELONEPHRITIS
• Is caused by bacterial infection and is the renal lesion
associated with urinary tract infection.
• Acute suppurative inflammation of the kidney caused
by bacterial and sometimes viral (e.g., polyomavirus)
infection, whether hematogenous and induced by
septicemic spread or ascending and associated with
vesicoureteral reflux.
 COMPLICATIONS OF ACUTE
PYELONEPHRITIS
• Papillary necrosis is seen mainly in diabetics and in
those with urinary tract obstruction.
• Usually bilateral but may be unilateral.
• Pyonephrosis is seen when there is total or almost
complete obstruction, particularly when it is high in
the urinary tract.
• The suppurative exudate is unable to drain and thus
fills the renal pelvis, calyces, and ureter with pus.
• Perinephric abscess is an extension of suppurative
inflammation through the renal capsule into the
perinephric tissue.
 CLINICAL FEATURES
• Predisposing conditions:
• Urinary tract obstruction, either congenital or acquired
• Instrumentation of the urinary tract, most commonly
catheterization
• Vesicoureteral reflux
• Pregnancy. Between 4% and 6% of pregnant women
develop bacteriuria sometime during pregnancy, and
20% to 40% of these eventually develop symptomatic
urinary infection if not treated.
 CLINICAL FEATURES CONTD….

• Gender and age. After the first year of life (when

congenital anomalies in males commonly become
evident) and up to around age 40 years, infections
are much more frequent in females. With increasing
age the incidence in males rises as a result of
prostatic hypertrophy and instrumentation.
• Preexisting renal lesions, causing intrarenal scarring
and obstruction
• Diabetes mellitus, in which increased susceptibility to
infection, neurogenic bladder dysfunction, and more
frequent instrumentation are predisposing factors
 CLINICAL FEATURES CONTD….

• When acute pyelonephritis is clinically apparent, the

onset is usually sudden, with pain at the costovertebral
angle and systemic evidence of infection, such as fever
and malaise.
• There are usually indications of bladder and urethral
irritation, such as dysuria, frequency, and urgency.
• The urine contains many leukocytes (pyuria) derived
from the inflammatory infiltrate, but pyuria does not
differentiate upper from lower urinary tract infection.
 CLINICAL FEATURES CONTD….

• The finding of leukocyte casts, typically rich in

neutrophils (pus casts), indicates renal involvement,
because casts are formed only in tubules.
• The diagnosis of infection is established by
quantitative urine culture.
• Uncomplicated acute pyelonephritis usually follows
a benign course, and the symptoms disappear
within a few days after the institution of
appropriate antibiotic therapy.
 CLINICAL FEATURES CONTD….

• Bacteria, however, may persist in the urine, or there

may be recurrence of infection with new serologic
types of E. coli or other organisms.
• Such bacteriuria then either disappears or may
persist, sometimes for years. In the presence of
unrelieved urinary obstruction, diabetes mellitus, or
immunodeficiency, acute pyelonephritis may be more
serious, leading to repeated septicemic episodes.
• The superimposition of papillary necrosis may lead to
acute renal failure.
 CHRONIC PYELONEPHRITIS
• More complex disorder; bacterial infection plays a dominant
role, but other factors (vesicoureteral reflux, obstruction) are
involved in its pathogenesis.
• Chronic pyelonephritis is a disorder in which chronic
tubulointerstitial inflammation and renal scarring are
associated with pathologic involvement of the calyces and
pelvis.
• Important cause of end-stage kidney disease.
• This condition remains an important cause of kidney
destruction in children with severe lower urinary tract
abnormalities.
 CHRONIC PYELONEPHRITIS CONTD….

• Chronic pyelonephritis can be divided into two forms:

chronic reflux-associated and chronic obstructive.
 REFLUX NEPHROPATHY

• More common form of chronic pyelonephritic

scarring.
• Renal involvement occurs early in childhood as a
result of superimposition of a urinary infection on
congenital vesicoureteral reflux and intrarenal reflux.
• May be unilateral or bilateral; thus, the resultant
renal damage may cause scarring and atrophy of one
kidney or involve both, leading to chronic renal
insufficiency.
• Vesicoureteral reflux occasionally causes renal
damage in the absence of infection (sterile reflux),
 CHRONIC OBSTRUCTIVE
PYELONEPHRITIS
•Recurrent infections superimposed on diffuse or localized
obstructive lesions lead to recurrent bouts of renal
inflammation and scarring, resulting in a picture of chronic
pyelonephritis.
•The effects of obstruction contribute to the parenchymal
atrophy; indeed, it is sometimes difficult to differentiate the
effects of bacterial infection from those of obstruction alone.
•The disease can be bilateral, as with posterior urethral valves,
resulting in renal insufficiency unless the anomaly is corrected,
or unilateral, such as occurs with calculi and unilateral
obstructive anomalies of the ureter.
 XANTHOGRANULOMATOUS
PYELONEPHRITIS
• Unusual and relatively rare form of chronic
pyelonephritis characterized by accumulation of
foamy macrophages intermingled with plasma cells,
lymphocytes, polymorphonuclear leukocytes, and
occasional giant cells.
• Often associated with Proteus infections and
obstruction, the lesions sometimes produce large,
yellowish orange nodules that may be grossly
confused with renal cell carcinoma.
 CLINICAL FEATURES

• Insidious in onset or present with clinical

manifestations of acute recurrent pyelonephritis, such
as back pain, fever, frequent pyuria, and bacteriuria.
• Chronic pyelonephritis associated with reflux may
have a silent onset.
• These patients come to medical attention relatively
late in the course of their disease because of the
gradual onset of renal insufficiency and hypertension
or because of the discovery of pyuria or bacteriuria on
routine examination
 CLINICAL FEATURES CONTD….

• Reflux nephropathy is often discovered when

hypertension in children is investigated.
• Loss of tubular function—in particular of
concentrating ability—gives rise to polyuria and
nocturia. Radiographic studies show asymmetrically
contracted kidneys with characteristic coarse scars
and blunting and deformity of the calyceal system.
Significant bacteriuria may be present, but it is often
absent in the late stages.
 PYELONEPHRITIS
• Serious complication of urinary tract infections that
affect the bladder (cystitis), the kidneys and their
collecting systems (pyelonephritis), or both.
• Bacterial infection of the lower urinary tract may be
completely asymptomatic (asymptomatic bacteriuria)
and most often remains localized to the bladder
without the development of renal infection.
• However, lower urinary tract infection always carries
the potential of spread to the kidney.
 ETIOLOGY
• The dominant etiologic agents, accounting for more
than 85% of cases of urinary tract infection, are the
gram-negative bacilli that are normal inhabitants of
the intestinal tract.
• Most common is Escherichia coli, followed by
Proteus, Klebsiella, and Enterobacter.
 ETIOLOGY CONTD….

• Streptococcus faecalis, also of enteric origin,

staphylococci, and virtually every other bacterial and
fungal agent can also cause lower urinary tract and
renal infection.
• In immunocompromised persons, particularly those
with transplanted organs, viruses such as
Polyomavirus, cytomegalovirus, and adenovirus can
also be a cause of renal infection.
 ETIOLOGY CONTD….

• In most patients with urinary tract infection, the

infecting organisms are derived from the patient's
own fecal flora.
• This is thus a form of endogenous infection.
 ETIOLOGY CONTD….

• There are two routes by which bacteria can reach the

kidneys:
• (1) through the bloodstream (hematogenous
infection) and
• (2) from the lower urinary tract (ascending infection).
 ETIOLOGY CONTD….

• The hematogenous route is the less common of the

two and results from seeding of the kidneys by
bacteria from distant foci in the course of septicemia
or infective endocarditis.
• Hematogenous infection is more likely to occur in the
presence of ureteral obstruction, in debilitated
patients, in patients receiving immunosuppressive
therapy, and with nonenteric organisms, such as
staphylococci and certain fungi and viruses.
• Ascending infection is the most common cause of
clinical pyelonephritis.
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