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Chronic Pyelonephritis and Arterial Hypertension

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Chronic Pyelonephritis and Arterial Hypertension CHRONIC PYELONEPHRITIS AND ARTERIAL HYPERTENSION Allan M. Butler J Clin Invest. 1937;16(6):889-897. https://doi.org/10.1172/JCI100915. Research Article Find the latest version: https://jci.me/100915/pdf CHRONIC PYELONEPHRITIS AND ARTERIAL HYPERTENSION By ALLAN M. BUTLER (From the Department of Pediatrics of the Harvard Medical School and the Infants' and Children's Hospitals, Boston) (Received for publication July 7, 1937) T'he present paper presents certain clinical and was interpreted as essential hypertension with pathological evidence which demonstrates that hy- superimposed diffuse acute pyelonephritis but pertension not infrequently is associated with without renal insufficiency. Twenty-six patients pyelonephritis before there is any appreciable dim- who suffered from diffuse chronic pyelonephritis inution in renal function and that hypertension were also studied; of these, hypertension and which is secondary to unilateral pyelonephritis uremia were associated in sixteen; hypertension may disappear when the involved kidney is re- alone was present in four, and uremia without moved. hypertension in six. Hypertension without Ritter and Baehr (1) described renal arteriolar marked renal insufficiency, therefore, was present sclerosis in congenital polycystic disease of the in six of their patients. In the majority of in- kidney and remarked upon a preliminary period stances, they were unable to decide whether they of arterial hypertension, cardiac hypertrophy and were dealing with a primary " vascular " hyper- hyposthenuria that usually precedes the terminal tension or with a secondary " renal " hypertension. uremia in that disease. Bell and Pedersen (2) In spite of the frequency with which pyelone- stated that " hypertension has never been reported phritis is encountered in childhood (12), we have in pyelonephritis." Volhard (3) and Schwarz found no report of a serious hypertension oc- (4) reported hypertension-in patients with con- curring in the pyelonephritis of childhood before tracted kidneys (schrumpfnieren). Longcope renal insufficiency was present. Interestingly and Winkenwerder (5) reported elevated blood enough, Amberg ( 13) in reporting twenty-five pressures in the uremic phase of cases of chronic cases of hypertension in children included five pyelonephritis. Weiss, Parker and Robb (6) patients with pyuria or bacilluria but made no par- observed that patients with malignant hyperten- ticular comment upon the presence of pyelonephri- sion frequently had a history of chronic pyelone- tis in these patients. phritis, pyelitis, or perinephritic abscess. They The records concerning the blood pressures of suggested that such a renal infection may heal but many of the patients admitted to this hospital with that the hypertension in'itiated by it may continue chronic pyelonephritis are not complete enough to to progress. Fishberg (7) mentioned the hyper- supply accurate information concerning the re- tension that may occur in children in the presence spective times at which the hypertension, if pres- of urinary obstruction and in polycystic disease ent, and renal insufficiency first appeared, but such of the kidney when there is extensive destruction data as are available seem significant. During the of renal parenfchyma. He stated, however, that past ten years fifteen children between three and hypertension does not occur in that disease if there eleven years of age were shown at necropsy to are extensive areas of intact parenchyma. Peters have pyelonephritis. Adequate records of the (8), Peters, Lavietes and Zimmerman (9), and blood pressures of seven of these patients are not Zimmerman and Peters (10) have called attention available. The records of the blood pressures for to the frequency with which pyuria and eclampsia the remaining eight patients show systolic pres- are associated in pregnancy and suggested a re- sures ranging from 250 to 140 mm. Hg and dia- lation between urinary tract infection and hyper- stolic pressures from 170 to 110 mm. Hg, the tension. Kimmelstiel and Wilson (11) studied average systolic and diastolic pressures being re- thirteen patients with acute diffuse pyelonephritis; spectively, 190 and 140 mm. Hg. Two of these nine died in uremia, and hypertension was present patients (Cases 3 an'd 4 reported below) had hy- in four of these. Two patients presented what pertensive crises and died of cardiac failure before 889 890 ALLAN M. BUTLER significant nitrogen retention occurred. The clini- definite proof that the pyelonephritis preceded the cal histories of two others of the group studied hypertension. pathologically indicated that the pyelonephritis The fifth case reported here is that of a patient and hypertension preceded severe nitrogen reten- who, coincident with a ureteral calculus, was tion. During the same ten year period three pa- found to have a unilateral pyelonephritis and dur- tients with pyelonephritis and hypertension died ing the course of the next 8 months developed and permission for autopsy was not obtained. hypertension and cardiac failure. The removal of The histories of two of these patients (Cases 1 the one infected kidney was followed by clearing and 2 below) indicate that the pyelonephritis and of the urine and a return of the blood pressure to hypertension preceded significant* renal insuffi- normal where it has remained for 20 months. ciency and nitrogen retention. During this same In this case there is strong evidence th-at the pye- *'-Fi9 [' A#f s,I ts Mbiiz, FIG. 1.P HOTOMICROGRAPH OF MICROSCOPIC SECTION PREPARED FROM KIDNEY. OF CASE 4 Hematoxylin and eosin. Reduced from a magnification of 240 di- ameters. Note prominence and thickening of walls of small arterioles, interstitial infiltration and casts in the renal tubules. Both chronic pyelo- nephritis and nephrosclerosis were present in the various sections examined. period nine patients with pyelonephritis and hy- lonephritis preceded the hypertension and in some pertension were admitted to the hospital and when way had a causal relation to it. last seen were living. Of these patients only one Subsequently, another patient, Case 6, who had had renal insufficiency, and in this one the pyelo- a unilateral pyelonephritis and hypertension which nephritis and hypertension preceded the appear- was relieved by right nephrectomy, and whose ance of the diminished renal function. history suggested a relation between the renal Thus we have fifteen patients (six dead and lesion and hypertension, was seen on the pediatric nine living) who have had chronic pyelonephritis ward of the Massachusetts General Hospital through the kindness of Dr. Harold Higgins and and hypertension over a period of years before Dr. J. D. Barney.' there was appreciable diminution in kidney func- 1 A full report of this patient will be made by Dr. tion. The detailed records of four of these pa- Barney. It is through his kindness that a brief descrip- tients are given below. In these cases there is no tion is given with the cases reported here. PYELONEPHRITIS AND HYPERTENSION 891 DISCUSSION tients who suffered from both pyelonephritis and It is of particular interest in relation to the last hypertension. two patients that A/foritz (14) reported three pa- A detailed review of the clinical observations tients with essential hypertension in each of whom concerning the association of pyelonephritis and the renal arteriolar sclerosis was found at ne- hypertensioni in patients studied in this hospital, cropsy to be limited to one kidney. however, led to the hypothesis that the hyperten- Both chronic pyelonephritis and nephrosclerosis sion might well be related to the local effect of the were revealed by postmortem examinations per- pyelonephritis rather than to the renal insuffici- formed on two of our patients (Cases 3 an'd 4). ency encountered late in the disease. When this The photomicrograph shown in Figure 1 illus- hypothesis was put to an empirical test by the re- trates the extensive character of the renal ar- moval of the infected kidney in a patient who teriolar sclerosis in Case 4. From the clinical ex- suffered from unilateral pyelonephritis and hyper- m FIG. 2. PHOTOMICROGRAPH OF MICROSCOPIC SECTION PREPARED FROM THE KIDNEY REMOVED FROM CASE 5 Hematoxylin and eosin. Reduced from a magnification of 240 di- ameters. Note diffuse pyelonephritis. No thickening of arterioles com- parable to that noted in Case 4 is demonstrable. amination of the retinal and peripheral vessels it tension (Case 5) it was found to be effective. is proable that nephrosclerosis was present in ad- The results in Dr. Barney's case (Case 6) lend dition to the pyelonephritis in Cases 1 and 2. It further support to such a relation between the is clear that no conclusion may be drawn from our pyelonephritis and hypertension. evidence in these four cases concerning' the rela- Pathological examination of the kidney re- tive time of onset of the pyelonephritis and the moved from our patient, Case 5, showed in ad- nephrosclerosis or their relative importance in the dition' to severe pyelonephritis very early sclerosis production of hypertension. The same difficulty of the renal arterioles. These vascular lesions was encountered by Kimmelstiel and Wilsoh ( 11) were not sufficiently advanced or prominent to when they attempted to decide whether they were merit the term of nephrosclerosis as it is ordi- dealing with primary " vascular " hypertension or narily understood. The photomicropraph of Fig- with secondary " renal " hypertension in their pa- ure 2 illustrates the absence in Case 5 of such a 892 ALLAN M. BUTLER renal arteriolar sclerosis as observed in Case 4. broad. There was a blowing systolic murmur and It is well known that chronic inflammatory proc- marked accentuation of the aortic second sound. The peripheral arteries were thickened but not beaded. The esses of various kinds are accompanied by vas- systolic blood pressure was 280 and the diastolic 170 mm. cular changes in the involved areas. In consider- Hg. The right kidney was palpable. The red blood cell ing the r6le of ischemia and infections in the pro- count was 3,700,000 per cu. mm. The hemoglobin was 72 duction of hypertension, it is of interest that per cent.
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