Dr. med. Dirk Manski

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Chronic Pyelonephritis

Definition of chronic pyelonephritis

Chronic pyelonephritis is a chronic relapsing inflammatory destruction of renal tissue (chronic tubulo-interstitial nephritis) and is usually caused by relapsing ascending urinary tract infections (acute pyelonephritis). A precise definition of chronic pyelonephritis does not exist (Dalla-Palma and Pozzi-Mucelli, 2000).

Epidemiology of chronic pyelonephritis

The proportion of chronic pyelonephritis as a cause of end-stage renal disease in children is up to 20%, but the frequency decreases.

Pathology of Chronic Pyelonephritis

Etiology of Chronic Pyelonephritis

Relapsing Acute Pyelonephritis:

Recurrent acute pyelonephritis in childhood results in renal scarring. New renal scars develop seldom after the age of 5 years, but are possible until puberty. The frequency of febrile urinary tract infections in children correlates with the severity of the scarring and the risk of chronic pyelonephritis. See also section acute pyelonephritis.

Vesicoureteral Reflux:

Since vesicoureteral reflux (VUR) causes recurrent urinary tract infections, VUR is also an important risk factor for chronic pyelonephritis (reflux nephropathy). The severity of chronic pyelonephritis correlates with the severity of vesicoureteral reflux and reflux nephropathy is a common cause of end-stage renal disease in children.

In some cases, however, severe vesicoureteral reflux does not lead to chronic pyelonephritis. In animal experiments, only vesicoureteral reflux with infected urine causes renal scarring, sterile reflux is not harmful. This finding was confirmed in human clinical trials and is the basis for successful antibiotic prophylaxis in vesicoureteral reflux.

Neurogenic Bladder Dysfunction:

Neurogenic bladder dysfunction may lead, comparable to vesicoureteral reflux, to chronic pyelonephritis by ascending infections and intrarenal reflux. Important risk factors are high bladder pressures in the storage phase or during micturition.

Other Risk Factors:

Diabetes mellitus, nephrolithiasis, chronic catheterization.

Pathophysiology of Chronic Pyelonephritis

Ask-Upmark Kidney:

The Ask-Upmark kidney is a special form of chronic pyelonephritis with an activated renin-angiotensin-aldosterone system (RAAS). The RAAS activation leads to secondary hyperaldosteronism and severe arterial hypertension which results in further vascular injury and progressive renal insufficiency.

Renal Insufficiency:

Chronic pyelonephritis with bilateral involvement and severe scarring may lead to end-stage renal disease.

Signs and Symptoms of Chronic Pyelonephritis

Diagnostic Work-up of Chronic Pyelonephritis

Treatment of Chronic Pyelonephritis

The cornerstones of treatment in chronic pyelonephritis are the consequent antibiotic therapy of urinary tract infections and the treatment of all above mentioned risk factors (vesicoureteral reflux, neurogenic bladder dysfunction, arterial hypertension).

Indication for nephroureterectomy: unilateral manifestation of chronic pyelonephritis with organ dysfunction to control recurrent urinary tract infection or arterial hypertension.

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Dalla-Palma und Pozzi-Mucelli 2000 DALLA-PALMA, L. ; POZZI-MUCELLI, F.:
[The imaging of chronic renal infections].
In: Radiologe
40 (2000), Nr. 6, S. 537–46

  Deutsche Version: Chronische Pyelonephritis