Chronic pyelonephritis

Chronic pyelonephritis

Chronic Pyelonephritis
Author: Tanner Marshall, MS
Editor: Rishi Desai, MD, MPH

With chronic pyelonephritis, pyelo- means pelvis, and -neph- refers to the kidney, so in this case its the
renal pelvis, which is the funnel-like structure of the kidney that drains urine into the ureter, and -itis
means inflammation. This inflammation is usually caused by bacterial infection of the kidney, which is
called acute pyelonephritis. When somebody has recurrent episodes of acute pyelonephritis, the kidney
becomes visibly scarred, at which point its referred to as chronic pyelonephritis.

Now a urinary tract infection, or UTI, is any infection of the urinary tract, which includes the upper portion
of the tractthe kidneys and the ureters, and the lower portion of the tractthe bladder and urethra. So
acute and chronic pyelonephritis are types of upper urinary tract infection.
Now, an episode of acute pyelonephritis often clears up without much complication. Certain people,
Chronic pyelonephritis
though, are predisposed to having recurring bouts of acute pyelonephritis, which eventually leads to
chronic pyelonephritis and permanent scarring of the renal tissue.

The most common risk factor for recurrent acute pyelonephritis and therefore chronic pyelonephritis, is
vesicoureteral reflux, or VUR, which is where urine is allowed to move backward up the urinary tract,
which can happen if the vesicoureteral orifice fails. The vesicoureteral orifice is the one-way valve that
allows urine to flow from each ureter into the bladder, but not in the reverse direction. VUR can be the
result of a primary congenital defect or it can be caused by bladder outlet obstruction, which increases
pressure in the bladder and distorts the valve.

That being said, chronic obstruction is its own independent risk factor for chronic pyelonephritis.
Obstructions in the urinary tract causes urinary stasis, meaning it tends to cause urine to stand still,
which makes it easier for bacteria to adhere to and colonize the tissue, making lower UTIs more likely
and therefore upper UTIs more likely. Bilateral obstruction increases pressure in the bladder and
therefore affects both kidneys, causes include congenital malformations, like posterior urethral valve,
which obstructs the flow of urine through the urethra, as well as benign prostatic hyperplasia in men,
which is an enlarged prostate, and cervical carcinoma in women, both of which can compress the
urethra shut. Obstructions could be unilateral as well, which would be a little higher and affect only one
kidney, as in the case of urinary calculi or kidney stones.
 Chronic pyelonephritis

Although one episode of inflammation might not lead to any permanent damage, recurrent episodes of
inflammation eventually leads the renal interstitium to undergo fibrosis and scarring, and the tubules
atrophy, andthese changes are generally found on the upper and lower poles of the kidney.

Also, on imaging studies like for example, computed tomographic urogram or CTU, the renal
calyces become blunted or flattened. On histology, some tubules might be dilated and full of glassy-
appearing proteinaceous material, called colloid, that forms as a result of the chronic inflammation. This
material ends up being shaped like the tubules and therefore forms colloid casts. Since this material
happens to look a little like thyroid tissue, this process is sometimes referred to as thyroidization of the
kidney. Those colloid casts can then get peed out and show up in the urine.
 Chronic pyelonephritis
A rare type of chronic pyelonephritis is called xanthogranulomatous pyelonephritis, or just XGP, which
happens when an infected kidney stone causes chronic obstruction. The combination of infection and
the increased pressure creates granulomatous tissue, which is full of foamy or fat-laden macrophages
and can easily be confused for a kidney tumor on imaging.

Treatment for chronic pyelonephritis involves correcting the underlying cause of recurrent infection,
which could be surgery to correct congenital structural causes or to remove obstruction like kidney
stones. In some cases, though, dialysis or nephrectomy, which is removal of some or all of a kidney,
might be needed.

Alright, as a quick recap, chronic pyelonephritis is where the kidney develops permanent scarring as a
result of recurring bouts of acute pyelonephritis, which is bacterial infection and inflammation of the
kidney. The two major predisposing factors to developing chronic pyelonephritis are vesicoureteral
reflux and chronic obstruction.
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Sources:
https://en.wikipedia.org/wiki/Pyelonephritis
https://en.wikipedia.org/wiki/Vesicoureteral_reflux
Pathoma
Robbins Basic Pathology, 9th Ed.
First Aid 2016

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