Chronic Pyelonephritis.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also . Good for self study also. Display blank slide> Think what you already know about this > Read next slide . See notes for bibliography.

2. Introduction

3. Introduction Chronic pyelonephritis is characterized by renal inflammation and fibrosis

4. Etiology

5. Etiology Recurrent or persistent renal infection, Vesicoureteral reflux Urinary tract obstruction. It occurs almost exclusively in patients with major anatomic anomalies, most commonly in young children with vesicoureteral reflux (VUR).

6. VUR- Vesicoureteral Reflux VUR is a congenital condition that results from incompetence of the ureterovesical valve due to a short intramural segment.  Rarely caused by neurogenic bladder.

7. VUR >pyelonephritis 7

8. Clinical Features

9. Clinical Features It’s a silent killer Some children with chronic pyelonephritis may report the following: Fever Lethargy Nausea and vomiting Flank pain or dysuria

10. Clinical Features Physical examination: Hypertension Failure to thrive in young children Flank tenderness

11. Differential Diagnosis

12. Differential Diagnosis Analgesic abuse nephropathy, renal tuberculosis, renal dysplasia, xanthogranulomatous pyelonephritis Hypertension Nephrolithiasis Perinephric Abscess Pyelonephritis, Acute Pyonephrosis

13. Diagnostic Studies/Workup Renal ultrasonography - Calculi Hydronephrosis Hydroureter Contracted kidney

14. Diagnostic Studies/Workup Voiding cystourethrogram (VCUG) / Micturating cystourethrogram Cystoscopy findings show evidence of previous reflux Radioisotopic scanning with technetium dimercaptosuccinic acid -renal scars. 

15. Diagnostic Studies/Workup  Intravenous urogram (IVU)/ Intravenous pyelogram (IVP)- Caliceal dilatation and blunting with cortical scars. Ureteral dilatation Reduced renal size .

16. Diagnostic Studies/Workup  Urinalysis – pyuria . Proteinuria may be present and is a negative prognostic factor for chronic pyelonephritis

17. Diagnostic Studies/Workup Urine culture-gram-negative bacteria, such as  Escherichia coli  or  Proteus  species. A negative result from urine culture does not exclude a diagnosis of chronic pyelonephritis.

18. Diagnostic Studies/Workup Serum creatinine and blood urea nitrogen levels are elevated ( azotemia ).

19. Diagnostic Studies/Workup Renal biopsy -focal glomerulosclerosis  

20. Management

21. Management Stages I and II This is reflux of urine to the ureter or renal pelvis without ureteral dilatation. Medical therapy with antibiotics- amoxicillin, trimethoprim/sulfamethoxazole trimethoprim alone, nitrofurantoin Continue antibiotic therapy until puberty or until reflux resolves.

22. Management Indications for surgical therapy: Failure to comply with medical regimen, with formation of new scars Breakthrough infections occurring in patients who are compliant Women of childbearing age who prefer surgical therapy Reflux persisting after puberty in women All children older than 1 year with bilateral reflux 

23. Surgery

24. Surgery Reimplantation of ureters. Nephrectomy.

25. pyonephrosis . .

26. pyonephrosis . . Urinary tract obstruction in the presence of pyelonephritis may lead to the collection of white blood cells (WBCs), bacteria, and debris in the collecting system.

27. Clinical Features  

28. Clinical Features  Fever Chills Flank pain Some patients may be asymptomatic.  Septic shock.

29.  Ascending infection of the urinary tract hematogenous spread of a bacterial pathogen. [

30. Risk factors

31. Risk factors Immunosuppression due to medications ( eg , steroids), disease ( eg , diabetes mellitus, acquired immunodeficiency syndrome [AIDS]), any anatomic urinary tract obstruction ( eg , stones, tumors , ureteropelvic junction [UPJ] obstruction, pelvic kidney, horseshoe kidney).

32. Diagnostic Studies

33. Diagnostic Studies A complete blood cell count (CBC) Blood urea nitrogen (BUN) and creatinine , Urinalysis with culture Blood cultures Abdominal sonography - The presence of debris and layering of low-amplitude echoes in the hydronephrotic kidney  CT scan  Diffusion MRI

34. Management

35. Management Problem Solution Infection IV Antibiotics Obstruction Relieve obstruction Stenting Nephrostomy Nephrectomy

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