1
|
Bolger MP, Hennebry J, Byrne C, Greene L, Stroiescu A, Heneghan J, Ryan AG. Xanthogranulomatous Pyelonephritis: A Narrative Review with Current Perspectives on Diagnostic Imaging and Management, Including Interventional Radiology Techniques. Int J Nephrol Renovasc Dis 2021; 14:359-369. [PMID: 34522121 PMCID: PMC8434833 DOI: 10.2147/ijnrd.s236552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/12/2021] [Indexed: 12/23/2022] Open
Abstract
Xanthogranulomatous Pyelonephritis (XGP) is a rare, chronic granulomatous inflammatory condition thought to arise secondary to a combination of obstruction, recurrent bacterial infection and an incomplete immune response resulting in focal or diffuse renal destruction. This destruction may be profound with the potential to infiltrate surrounding tissues and viscera. The imaging features of XGP can be ambiguous, mimicking malignancy, tuberculosis (TB) and malakoplakia earning the title of "the great imitator". Computed tomography (CT) is the mainstay of XGP diagnosis and staging, accurately quantifying the stone burden and staging the renal destruction, including the extent of extra-renal spread. Although some cases in children have been successfully treated with antibiotics alone, nephrectomy remains the most common treatment for XGP in adults. The specific management strategy needs to be tailored to individual patients given the potential constellation of renal and extrarenal abnormalities. Although XGP has classically required open nephrectomy, laparoscopic nephrectomy has an increasing role to play arising from the advancement in laparoscopic skills, technique and instruments. Nephron-sparing partial nephrectomy may be considered in the focal form. Interventional radiology techniques most often play a supportive role, eg, in the initial drainage of associated abscesses, but have rarely achieved renal salvage. This narrative review seeks to synthesise the existing literature and summarise the radiological approach and interventional radiology management situated in a clinical context.
Collapse
Affiliation(s)
- Mark Paul Bolger
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Jennifer Hennebry
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Caoimhe Byrne
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Laura Greene
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Andreea Stroiescu
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Joan Heneghan
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| | - Anthony Gerard Ryan
- Division of Interventional Radiology, Department of Radiology, University Hospital Waterford, Waterford City, X91 DWX0, Ireland
| |
Collapse
|
2
|
Val-Bernal JF, Garijo MF. Xanthogranulomatous Pyelonephritis Associated with Systemic Amyloidosis. Int J Surg Pathol 2016. [DOI: 10.1177/106689699800600107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - M. Francisca Garijo
- Anatomical Pathology Department, Marques de Valdecilla University Hospital, Medical Faculty, University of Cantabria, Santander, Spain
| |
Collapse
|
3
|
Bilbao Garay J, Zapatero Gaviria A, Domínguez Frajo P, Llorente Abarca C, Fernández Juárez G. Amiloidosis secundaria a pielonefritis xantogranulomatosa: presentación de un caso y revisión de la literatura. Rev Clin Esp 2006; 206:43-7. [PMID: 16527048 DOI: 10.1157/13084769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- J Bilbao Garay
- Unidadad de Medicina Interna, Fundación Hospital Alcorcón, Madrid.
| | | | | | | | | |
Collapse
|
4
|
Chen HJ, Tsai JD, Lee HC, Chiu NC, Sheu JC, Shih SL, Tzen CY. Diffuse xanthogranulomatous pyelonephritis in a child with severe complications. Pediatr Nephrol 2004; 19:1408-12. [PMID: 15378422 DOI: 10.1007/s00467-004-1627-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Hui-Ju Chen
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
| | | | | | | | | | | | | |
Collapse
|
5
|
Abstract
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.
Collapse
Affiliation(s)
- F M Quinn
- Department of Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Republic of Ireland
| | | | | | | | | |
Collapse
|
6
|
Noyan A, Duman N, Gönlüşen G, Anarat A, Tuncer I. Amyloidosis secondary to xanthogranulomatous pyelonephritis: an unusual case. Pediatr Nephrol 1995; 9:251. [PMID: 7646703 DOI: 10.1007/bf00860764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
7
|
Hazenberg BP, van Rijswijk MH. Clinical and therapeutic aspects of AA amyloidosis. BAILLIERE'S CLINICAL RHEUMATOLOGY 1994; 8:661-90. [PMID: 7954868 DOI: 10.1016/s0950-3579(05)80121-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Approach to the management of AA amyloidosis complicating RA. (A) In case of proteinuria or loss of renal function a rectal biopsy or a subcutaneous fat biopsy is a suitable screening method for the detection of amyloidosis. If in any doubt, try to ascertain the diagnosis by renal biopsy. Adequate staining with alkaline Congo red and preferably immunohistochemical staining with anti-AA antibodies should be performed. Beware of renal pathology other than amyloidosis even in the presence of a positive rectal biopsy. (B) A vigorous attempt to control disease activity of the RA should be made in order to eliminate the production of SAA, an acute phase protein. The response to treatment should be monitored by serial measurements of CRP and preferably SAA. (C) The function of some vital organs should be evaluated: (a) endogenous creatinine clearance and the extent of proteinuria; (b) electrocardiogram and optional echocardiography; (c) thyroid function and adrenocortical function; (d) intestinal absorption tests; (e) optional--SAP scintigraphy and turnover studies. (D) Attention should be given to adequate supportive treatment: (a) blood pressure control; (b) treatment of intercurrent infections; (c) corticosteroids during major surgical procedures; (d) pay attention to the possible effect of NSAID on proteinuria and renal function. (E) In case of total renal failure or uncontrollable proteinuria: (a) consider the possibility of primary renal transplantation; (b) otherwise regular haemodialysis is indicated.
Collapse
Affiliation(s)
- B P Hazenberg
- Division of Rheumatology, University Hospital Groningen, The Netherlands
| | | |
Collapse
|
8
|
Akhtar M, Kardar AH, Linjawi T. Xanthogranulomatous pyelonephritis: King Faisal Specialist Hospital experience. Ann Saudi Med 1993; 13:19-25. [PMID: 17587985 DOI: 10.5144/0256-4947.1993.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- M Akhtar
- Departments of Pathology, Surgery and Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | |
Collapse
|
9
|
Affiliation(s)
- M T Flynn
- Department of Nephrology, Children's Hospital, Dublin, Ireland
| | | |
Collapse
|
10
|
Akhtar M, Qunibi W. Bilateral xanthogranulomatous pyelonephritis involving native kidneys in a renal transplant recipient: association with renal cell carcinoma and amyloidosis. Am J Kidney Dis 1992; 20:289-93. [PMID: 1519612 DOI: 10.1016/s0272-6386(12)80704-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Akhtar
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | |
Collapse
|
11
|
Lauzurica R, Felip A, Serra A, Saladie JM, Montserrat E, Encabo B, Caralps A. Xanthogranulomatous pyelonephritis and systemic amyloidosis: report of 2 new cases and the natural history of this association. J Urol 1991; 146:1603-6. [PMID: 1942352 DOI: 10.1016/s0022-5347(17)38181-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- R Lauzurica
- Department of Nephrology, Hospital de Badalona Germans Trias i Pujol, Barcelona, Spain
| | | | | | | | | | | | | |
Collapse
|