Generalized amyloidosis secondary to xanthogranulomatous pyelonephritis

Xanthogranulomatous Pyelonephritis Associated with Systemic Amyloidosis

Xanthogranulomatous pyelonephritis is rarely associated with systemic amyloidosis. To the best of our knowledge, this association has been described in only nine cases, including the present report. Our first patient, a 76-year-old woman, presented with chronic renal failure and xanthogranulomatous pyelonephritis in the right kidney associated with amyloidosis in the same kidney and ipsilateral adrenal. She has been followed up for 44 months and continues to do well with stable renal function and mild proteinuria. Our second patient, a 54-year-old woman, had a 25-year history of recurrent Proteus mirabilis urinary tract infections. She developed anuric chronic renal failure, becoming dependent on dialysis, and xanthogranulomatous pyelonephritis in the left kidney associated with amyloidosis in the same kidney. She died at 8 days postsurgery. The combination of lesions has been described in childhood and in adults presenting with chronic renal failure or nephrotic syndrome. Clinical remission of amyloidosis develops in a majority of the patients after the removal of the renal lesion. From a pathologic point of view our cases underline the importance of careful histologic examination of removed kidneys, even in conditions characterized by extensive destruction of renal tissue. To prevent the association with amyloidosis we emphasize the importance of early diagnosis and treatment of xanthogranulomatous pyelonephritis.

Amiloidosis secundaria a pielonefritis xantogranulomatosa: presentación de un caso y revisión de la literatura

Xanthogranulomatous pyelonephritis (XGP) is a rare entity characterized by the formation of inflammatory renal masses rich in macrophages loaded with lipids. It is usually secondary to repeated urinary infections and urinary obstruction due to stones, which produce slow destruction of the renal parenchyma, requiring nephrectomy. It may sometimes be associated to secondary amyloidosis that leads to the appearance of a nephrotic syndrome. We have conducted a search in the Medline database between the years 1967 and 2003 and we only found 6 cases in adults and 3 cases in pediatric patients with amyloidosis secondary to xanthogranulomatous pyelonephritis. During this same period, there are more than 570 citations that include more than 1,000 patients with isolated XGP, so that we estimate that amyloidosis that complicates a XGP should be less than 1% of all the XGP cases. We present a case of XGP in a 51 year old female patient associated to amyloidosis that initiated with nephrotic syndrome, analyzing the clinical characteristics of the 9 previous cases. We compared their clinical characteristics with those of 51 patients with xanthogranulomatous pyelonephritis without amyloidosis of a large classical series in order to characterize this clinical picture better.

Diffuse xanthogranulomatous pyelonephritis in a child with severe complications

Xanthogranulomatous pyelonephritis is a rare disease in childhood. Because the symptoms and signs are chronic and non-specific, preoperative diagnosis is usually difficult. We report an 8-year-old boy who had an abdominal mass and anemia for more than 6 months. Fever and dyspnea occurred 4 days prior to admission. Ultrasonography revealed an enlarged right kidney with multiple parenchymal hypoechogenic areas, absence of normal parenchymal structures, and perinephric thickening with multiple calcifications. An abdominal computed tomogram demonstrated an irregular, enlarged right kidney with multiple low-density round areas consistent with hydronephrosis and calculi. Diminished excretion of contrast media and a severe perinephric inflammatory reaction were present. Poor right kidney function was demonstrated by Tc99m-diethylenetriamine penta-acetic acid split renal function examination. We diagnosed xanthogranulomatous pyelonephritis preoperatively based on the clinical and radiological features. The child first had drainage of an extrarenal abscess and antibiotic therapy, followed by definitive nephrectomy. The hospital course was complicated with pleural effusion, peritonitis, pelvic abscess, and sepsis. A two-stage nephrectomy requiring less radical resection and decreasing the surgical complications would have been preferable.

Xanthogranulomatous pyelonephritis in childhood

BACKGROUND

Xanthogranulomatous pyelonephritis is a severe, atypical form of chronic renal parenchymal infection accounting for 6/1000 surgically proved cases of chronic pyelonephritis. Its manifestations mimic those of neoplastic and other inflammatory renal parenchymal diseases and, consequently, it is often misdiagnosed preoperatively.

AIM

To examine the relation between clinical history and the results of renal investigations performed in children with xanthogranulomatous pyelonephritis.

METHOD

A retrospective review of 31 cases presenting with the histopathological diagnosis of xanthogranulomatous pyelonephritis between 1963 and 1999.

RESULTS

The mean follow up was 8.2 years. The male:female ratio was 1:1.1. The left kidney was affected in 26 of the 31 patients. The positive findings on examination and investigation at presentation were: fever, 16 children; pyuria, 26 children; positive urine culture, 16 children. A haemoglobin of < 100 g/l was measured in 27 of 31 patients and 15 of 18 patients tested had a raised erythrocyte sedimentation rate of > 20 mm in the first hour. Twenty six children had renal calculi, with a large reduction in the function of the affected kidney on isotope scintigraphy in 27 of the 29 patients tested. Hypertrophy of the contralateral kidney, shown on imaging, was present in 17 of 31 patients.

CONCLUSIONS

Increasing awareness of this condition should lead to the diagnosis being suspected preoperatively.

Xanthogranulomatous pyelonephritis: King Faisal Specialist Hospital experience

Clinicopathologic features in a series of 11 cases of xanthogranulomatous pyelonephritis are reviewed. There were seven males and four females ranging in age from 6-56 years with an average age of 34 years. The disease was unilateral in ten cases and bilateral in one. There was associated urinary tract obstruction in eight cases due to renal or ureteric stones (5), ureteric stricture (2), and carcinoma of the urinary bladder (1). Two of the patients were renal transplant recipients in which native kidneys were involved by xanthogranulomatous pyelonephritis. In one of these cases, a small renal cell carcinoma was found in one kidney along with amyloidosis involving both kidneys. Radiologic findings were mostly non-specific. These findings are briefly discussed in light of the salient features of this disease as published in the literature.

Bilateral xanthogranulomatous pyelonephritis involving native kidneys in a renal transplant recipient: association with renal cell carcinoma and amyloidosis

An unusual case of a 44-year-old male renal transplant recipient who developed bilateral xanthogranulomatous pyelonephritis (XPN) of his native kidneys is presented. Bilateral nephrectomy specimens showed classic features of XPN. In addition, there was amyloidosis involving both kidneys and a small renal cell carcinoma in the left kidney. To the best of our knowledge, such a combination of pathologic conditions in one patient has not been previously reported.

Xanthogranulomatous pyelonephritis and systemic amyloidosis: report of 2 new cases and the natural history of this association

The association of xanthogranulomatous pyelonephritis and systemic amyloidosis is extremely rare. To our knowledge, despite innumerable cases of xanthogranulomatous pyelonephritis reported in the literature, this association has been described on only 2 occasions. Clinical, analytical and radiographic findings can be highly suggestive of the diagnosis. We report on 2 patients with xanthogranulomatous pyelonephritis, systemic amyloidosis and the nephrotic syndrome: 1 died 4 1/2 years after diagnosis and 1 was stable with good general health 3 years after diagnosis. The clinical aspects as well as the treatment given to both patients are discussed. We describe the natural history of an association that due to its rarity is not currently well known.

Xanthogranulomatous pyelonephritis and amyloidosis: a rare association

The coincidence of systemic amyloidosis and xanthogranulomatous pyelonephritis has been reported previously only once. Clinical findings, such as the nephrotic syndrome, cardiac and autonomic nervous system dysfunction, and adrenal insufficiency, are suggestive and a thorough investigation to rule out other causes of secondary amyloidosis is warranted. We report a case of xanthogranulomatous pyelonephritis associated with secondary systemic amyloidosis and the nephrotic syndrome. Treatment consisted of nephrectomy and intensive supportive care. The unique clinical, radiographic and pathological aspects of this case are discussed.