1
fourth stage
Medicine (renal)
Lec-9
Dr.Emad
9/11/2015
Chronic interstitial nephritis (CIN)
Is a heterogeneous group of disease causing chronic inflammation within the tubules and
interstitium
.
Classification of CIN:-
Type of disease :
1-chronic glomerular disease in all types of glomerular nephritis a variable degree of IN
is associated .
2-immune –inflammatory disease sarcoidosis ;sjogrens syndrome;SLE ;transplantation
rejection ;Amyloidosis .
3-Tumors Myeloma
4-Drugs all drug causing AIN especially NSAID
5-Metabolic or congenital Wilsons disease, Hypokalemia ;hypercalciuria ;hyperoxaluria
,Sickle cell anemia
6- Toxins mushroom poison ;lead poison ;Chinese herbs ;Balkan nephropathy .
Clinical features
most patients present in adult life with CRF,HT and small kidney
minority of patients present with hypotension, polyuria and features of sodium and
water depletion "sodium losing nephropathy"
in Balkan nephropathy the condition is associated with tumor of collecting tubules
renal tubular acidosis is associated with myeloma, sarcoidosis and Amyloidosis
Management
1. full diagnostic work up for conditions mentioned
2. if CRF is developed usually requires conservative treatment
2
Infection of kidney and urinary tract
Usually UT is sterile and bacteria is localized to the lower end of urethra.
UTI indicates multiplication of organism in UT and is defined as presence of more than
100,000 organism/ml of mild stream urine (MSU)
Clinical presentation of UTI:
1-asymptomatic bacteriuria
2-urethritis and cystitis
3-acute prostitis
4-acute pyelonephritis
5-septicemia
Investigations of patient with UTI
1-GUE for all patients for RBCs,WBCs and pus
2-urine C&S : MSU, or suprapubic for all patients
3-dipstick examination for protein ,glucose and cells
4-full blood count :infant,children and adult
5-renal function tests (RFTs) : infant,acute pyelonephritis and recurrent UTI
6- blood culture : fever , rigor and septic shock
7-pelvic examination : in female with recurrent UTI
8- rectal examination: in male
9-IVU:
-in infant , children and adult male with severe UTI
-in female with : 1.acute pyelonephritis 2. recurrent UTI after treatment 3.recurrent UTI in
pregnancy
3
Acute pyelonephritis
Acute inflammation of renal pelvis and parenchyma usually with one or both kidney
Clinical picture
1-pain in one or both loin radiate to iliac fossa and suprapubic area
2-30% of patients has dysuria due to associated cystitis
3- fever, rigor and vomiting
4-hypotension And septicemia
5-tenderness in loin and renal angle guarding
6-blood examination shows leucocytosis
7-GUE for pus, RBC…..
-In infant acute pyelonephritis may present as fever without localizing symptoms, the initial
feature may be convulsion, apathy, abdominal distention and diarrhea may occur
-Rarely acute papillary necrosis may follow an attack of acute pyelonephritis and may lead
to renal failure, seen in DM,chronic UT obstruction and also may be seen in analgesic
nephropathy and sickle cell disease.
Differential diagnosis
1-appendicitis
2-oophoritis
3-cholecystitis
4-diverticulitis
5-perinephric abscess ( but this occur with clear urine)
Management
Diagnosis depend on clinical picture and urine culture and U/S of kidney, so we start
treatment with antibiotics as :
-trimethoprim
-amoxicillin 500mg t.i.d for 7 days
-gentamicin 2-3 mg/kg for 10 days
-ciprofloxacin
4
Analgesic nephropathy
Causes
1-renal papillary necrosis
2-chronic interstitial nephritis
3- account for E.S.R.D between 5-17% in western countries
Pathology
1-diffuse interstitial fibrosis
2-tubular atrophy
3-acute papillary necrosis
4-development of carcinoma in uroepithelium
Clinical features
1-patients are usually taking analgesic preparation for many years ( headache, backache, RA
or osteoarthritis)
2- patient may be asymptomatic and disease is discovered on routine examination of urine
or blood
3- patient may present with moderate renal impairment with polyuria and malaise
4- UTI is common
5-patient may present as a case of HT
6- patient may present with feature of salt-losing nephropathy
Diagnosis and investigations
1. History
2. Biochemical evidence of tubular dysfunction
3. IVU or retrograde pyelography is often characteristic ( ring shadow )
4. Urine examination may show red cells and sterile pyuria
5. Proteinuria rarely exceed 1gm/24h
5
Treatment
1. Stop analgesic ( 25% show some recovery )
2. Good and optimum fluid intake2-3 liter/day
3. Treatment of HT
4. Treatment of infection
5. Regular follow up
6. If CRF develops treatment as usual