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Putty kidney

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End stage of Renal Tuberculosis

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Putty kidney

  1. 1. PUTTY KIDNEY Dr. Mahesh Chaudhary Resident phase - B Radiology & imaging, BSMMU
  2. 2. INTRODUCTION • A putty kidney refers to a pattern of renal calcification associated with renal tuberculosis conventionally described on plain radiography. • Calcification is usually homogeneous and ground glass-like, representing calcified caseous tissue • Premkumar et al. Labelled calcification 'putty-like' if any faint area of uniform calcification was more than 1 cm in diameter • Lobar calcification represents an end-stage appearance, associated with autonephrectomy.
  3. 3. GENITOURINARY TUBERCULOSIS • The genitourinary tract is a primary target of hematogenous infections and is the most common site of extra-pulmonary TB • Genitourinary tuberculosis (GUTB), a term coined by Wildbolz in 1937 • A worldwide disease, but shows a more destructive behavior in developing countries • The kidney is the most common site of GUTB • Increased incidence of extra-pulmonary TB has been noted in AIDS
  4. 4. PATIENT POPULATION • GUTB usually affects adults between the second and fourth decades of life • There is often a long latent period (5-40 years) between the original pulmonary infection and the appearance of clinical renal disease, which is probably why renal involvement is rare before the age of 20 years
  5. 5. SYMPTOMS • Frequent voiding; dysuria; pyuria • Back, flank or abdominal pain • Microscopic or macroscopic hematuria • Hematuria and culture-negative pyuria may be seen at urine analysis • Urine analysis of sediment from a 24-hour specimen for acid-fast bacilli (AFB) is positive in 80-90% of cases of TB
  6. 6. RENAL TUBERCULOSIS • Renal tuberculosis, a subset of genitourinary tuberculosis, accounts for 15-20% of extra-pulmonary tuberculosis • Tuberculosis can involve both the renal parenchyma and the collecting system (calyces, renal pelvis, ureter, bladder and urethra) and results in different clinical presentations and radiographic appearances
  7. 7. PATHOLOGY • Renal infection results from hematogenous spread at the time of primary infection, with multiple micro-abscesses developing at the site of peri- glomerular capillary seeding • Usually there is a long latency between primary infection and presentation which in most case occurs due to host immunity becoming compromised • These quiescent granulomas then can reactivate, grow and eventually communicate with the calyces, leading to downstream infection
  8. 8. RADIOGRAPHIC FEATURES • Both the renal parenchyma and the upper collecting system (calyces and renal pelvis) can be involved • Infection limited to the renal parenchyma has two morphological appearances • Pyelonephritis • Appearances are similar to pyelonephritis caused by other organisms • Hypoperfusion and swelling of all or part of the kidney • Pseudotumoural type • Single or multiple nodules • Mimics renal cell carcinoma
  9. 9. • Usually the collecting system is involved (either in isolation or in combination with the parenchyma), and appearances vary according to the stage of disease • Early • Papillary necrosis (single or multiple) resulting in uneven caliectasis • Progressive • Multifocal strictures and hydronephrosis • Mural thickening and enhancement (on cross-sectional imaging) • End-stage • Progressive hydronephrosis and parenchymal thinning • Dystrophic calcification
  10. 10. PLAIN RADIOGRAPH • Plain film findings focus on calcification, which is seen in ~35% (range 25-45%), at various stages of disease: • Triangular in papillary necrosis • Focal or amorphous: putty kidney (end stage)
  11. 11. IVU • Traditional plain film IVU is quite sensitive to renal tuberculosis. • Features include: • Parenchymal scars 50% • Moth eaten calyces: early finding • Irregular caliectasis • Phantom calyx • Hydronephrosis
  12. 12. • Lower urinary tract signs • Kerr kink • Sawtooth ureter • Pipe-stem ureter • Beaded or corkscrew ureter • Thimble bladder
  13. 13. ULTRASOUND • Sonographic appearances are nonspecific and variable, depending on the stage of disease. • Early • Normal kidney or small focal cortical lesions with poorly defined border • Calcification +/- •End-stage •Small, shrunken kidney, "paper-thin" cortex and dense dystrophic calcification in collecting system •May resemble chronic renal disease
  14. 14. •Progressive o papillary destruction with echogenic masses near calyces o distorted renal parenchyma o irregular hypoechoic masses connecting to collecting system; no renal pelvic dilatatio o mucosal thickening +/- ureteric and bladder involvement o small, fibrotic thick-walled bladder o echogenic foci or calcification (granulomas) in bladder wall near ureteric orifice o localized or generalized pyonephrosis
  15. 15. • Ultrasound is less sensitive than CT in detection of: • Calyceal, pelvic or ureteral abnormalities • Isoechoic parenchymal masses • Small calcifications • Small cavities that communicate with collecting system
  16. 16. CT • CT is the most sensitive modality for visualizing renal calcifications and CT IVP is more sensitive at identifying all manifestations of renal tuberculosis • Early • Papillary necrosis (single or multiple) resulting in uneven caliectasis • End-stage • Progressive hydronephrosis results in very thin parenchyma, mimicking multiple thin walled cysts • Amorphous dystrophic calcification eventually involves the entire kidney (known as putty kidney)
  17. 17. • Progressive • Multifocal strictures can affect any part of the collecting system • Generalised or focal hydronephrosis • Mural thickening and enhancement • Poorly enhancing renal parenchyma, due to direct involvement or due to hydronephrosis
  18. 18. TREATMENT AND PROGNOSIS • Multi-drug treatment is essential, however despite treatment, structuring can progress • The role of nephrectomy is controversial • Nephrectomy, partial nephrectomy can be performed both open and endoscopically
  19. 19. DIFFERENTIAL DIAGNOSIS XANTHOGRANULOMATOUS PYELONEPHRITIS • Rare form of chronic pyelonephritis and represents a chronic granulomatous disease resulting in a non- functioning kidney • Female predilection (F:M 2:1) presumably relating to an increased incidence of urinary tract infections and thus struvite NEPHROCALCINOSIS • previous known as Anderson-Carr kidney or Albright's calcinosis, refers to the deposition of calcium salts in the parenchyma of the kidney • Types: • medullary nephrocalcinosis: 95% • cortical nephrocalcinosis: 5% • combined cortical and medullary nephrocalcinosis MEDULLARY SPONGE KIDNEY • Medullary sponge kidney is a sporadic condition where the medullary and papillary portions of the collecting ducts are dysplastic, and dilated and in most cases develop medullary nephrocalcinosis.
  20. 20. XANTHOGRANULOMATOU S PYELONEPHRITIS • A chronic granulomatous process • The kidney is eventually replaced by a mass of reactive tissue, surrounding the usually present (90%) inciting staghorn calculus with associated hydronephrosis of a greater or lesser degree. Foamy (lipid-laden) macrophages predominate • Fragmentation and enlargement of the the renal outline may be seen. A calculus is seen MEDULLARY NEPHROCALCINOSIS • Deposition of calcium salts in the medulla of the kidney. • Due to the concentrating effects of the loops of Henle, and the biochemical milieu of the medulla, compared to the cortex, it is 20 times more common than cortical nephrocalcinosis • Causes: hyperparathyroidism, medullary sponge kidney, renal tubular acidosis, hypervitaminosis D, milk- alkali syndrome, sarcoidosis. • Hypercalciuric states • Cushing syndrome • multiple myeloma • Bartter syndrome MEDULLARY SPONGE KIDNEY • It represents a developmental defect affecting the formation of collecting tubules and results in cystic dilatation of medullary and papillary portions of collecting ducts. • Clusters of pyramidal medullary calcification are characteristic. Delayed post contrast CT may demonstrate a "paint brush" appearance to the renal medullary regions
  21. 21. XGPN • Ultrasound examination demonstrates an enlarged and distorted renal outline, with loss of the normal renal architecture and (usually) a centrally-located shadowing calculus • CT findings are most helpful in reaching the correct diagnosis. The normal renal outline is lost and enlarged with a paradoxical contracted renal pelvis. The calyces in CORTICAL NC Causes: • renal cortical necrosis • chronic glomerulonephritis • Alport syndrome • chronic pyelonephritis • hyperoxaluria • oxalosis • vesicoureteral reflux (VUR) • nephrotoxic drugs, e.g. Amphotericin B • autosomal recessive polycystic kidney disease (ARPKD) MSK • On IVP, pyelogram may give a characteristic bouquet of flowers appearance • Ultrasound of the kidneys of patients with medullary sponge kidneys typically demonstrates echogenic medullary pyramids.
  23. 23. Thank you