Yale UniversityEliScholar – A Digital Platform for Scholarly Publishing at Yale

Yale Medicine Thesis Digital Library School of Medicine

1960

Chronic pyelonephritis at autopsySusan KleemanYale University

Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl

This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for ScholarlyPublishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A DigitalPlatform for Scholarly Publishing at Yale. For more information, please contact elischolar@yale.edu.

Recommended CitationKleeman, Susan, "Chronic pyelonephritis at autopsy" (1960). Yale Medicine Thesis Digital Library. 2798.http://elischolar.library.yale.edu/ymtdl/2798

YALE MEDICAL LIBRARY

3 9002 01069 4629

MUDD

LIBRARY

Medical

Digitized by the Internet Archive in 2017 with funding from

The National Endowment for the Humanities and the Arcadia Fund

https://archive.org/details/chronicpyelonephOOklee

CHRONIC PYELONEPHRITIS AT AUTOPSY

Susan Emily Thurman Kleeman

ABryn Mawr College

A thesis presented to the faculty of the

Yale University School of Medicine

in partial fulfillment of the

requirements for the Degree of

Doctor of Medicine

Department of Internal Medicine

I960

A* Nf y JU, 1960

v- UBRbK\

TH3 YU 2.30 6

To Frank

«*■

ACKNOWLEDGMENT

I wish to express rny gratitude to Dr» Lawrence R,

Freedman for his kind guidance, encouragement and patienc

in the preparation of this thesis,

I am also indebted to Dr* Averill A. Liebow for

his permission to study the pathological protocols and

microscopic slides*

Furthermore I wish to acknowledge the kind help of

Mrs* Jeanette Gardner and Mrs„ Leah West in obtaining

clinical records for me*

TABLE OF CONTENTS

I.

II.

III.

IV.

Vo

VI.

VII.

Introduction ..

Method and Materials ..

Results o.o............

Discussion ............

Summary and Conclusions

Appendix

Bibliography ..........

© <9

Page

1

3

8

32

50

52

54

TABLES AND FIGURES Page

Table 1, Chronic Pyelonephritis at Autopsy at G.N.H.C.H. January, 1957-January, 1959 ..».• 9

Table 2. Group I A - Chronic Pyelonephritis in the Absence of Genitourinary Tract Ab¬ normality in Males ....*.. . . .. .. . * .. . „.. .. *• 11

Table 3» Group I A - Chronic Pyelonephritis in the Absence of Genitourinary Tract Ab¬ normality in Females ................ 14

Table 4. Clinical and Pathological Correlates in Chronic Pyelonephritis in the Absence of Obstruction (Group I A) .................... 18

Table 5® Scarred Kidneys at Autopsy at G.N.H8C.H, January, 1957 - January, 1959 .. • * . ... •..,.. 23

Table 6. Group II A Scarred Kidneys with N.P.N.'s Greater than 85 rag. % and/or Contracted Kidneys in the Absence of Genitourinary Tract Abnormality in Males .................. 25

Table 7® Group II A Scarred Kidneys with N.P.N.’s Greater than 85 rag. % and/or Contracted Kidneys in the Absence of Genitourinary Tract Abnormality in Females ............... 26

Table 8. Clinical and Pathological Correlates in Scarred Kidney Group II A .................. 27

Table 9® Chronic Pyelonephritis at Autopsy .......... 34

Table 10. Hypertension in Chronic Pyelonephritis ..... 39

Table 11. Clinical Pyelonephritis .................... 44

Figure 1. Age Distrituion in Chronic Pyelonephritis- Group 1 A .................................. 36

Figure 2. Age Distribution in Scarred Kidneys - Group II A ................................. 37

-1-

INTRODUCTION

It is generally agreed that clinical pyelonephritis

in the absence of obstruction of the urinary tract is

primarily a disease of women (2, 33, 32, 1?, 10, 14).

A review of published cases, however, shows that

there has not been adequate documentation of this„ The

reported series suffer from one or more of the following

defects: a) obstructive disease of the urinary tract was

not excluded, b) bacteriologic evidence was derived from

broth cultures of urine, a procedure now known to be in¬

adequate for the diagnosis of urinary tract infection, and

c) many series do not distinguish the sexes or consider only

women.

In a recent study on the medical service of the Grace

New Haven Community Hospital where cases were selected on the

basis of quantitative urine bacteriology, clinical urinary

tract infection in the absence of obstruction was ten times

more frequent in women than in men thus documenting the prior-

noted impressions of most authors„

Chronic pyelonephritis is considered by most authors

to result from bacterial infection of the kidney (22, 42, 3,

17). If bacterial infection of the urinary tract is related

to chronic pyelonephritis at autopsy, one might expect to

find the sex incidence similar in the clinical and autopsy

-2-

studies. There Is reason to suspect from published data

(32, 14) that the sex incidence of chronic pyelonephritis at

autopsy in the absence of obstruction differs markedly from

the predicted ten to one. If this is indeed the case it would

necessitate a re-evaluation of the relationship between

clinical urinary tract infection and chronic pyelonephritis

at autopsy. The current impressions of chronic pyelonephritis

at autopsy are based upon relatively few studies, most of

which have not rigidly excluded from consideration cases

with obstruction of the genitourinary tract.

The present study was undertaken to examine the sex

incidence of chronic pyelonephritis at autopsy, observing

the precautions described above. During the course of the

study an attempt was made to examine other factors of interest

such as hypertension, family history for cardiovascular

disease, and renal disfunction as measured by elevation of

N.P.N.

-3-

METHOD AND MATERIALS

Collection of Data *

Of the 1,526 consecutive autopsies (57«^$ males and

42.6$ females) at the Grace New Haven Community Hospital over

the period from January, 1957 to January, 1959* ** two groups

of cases were selected for further study.

Group I — All cases with the final pathological

diagnosis of chronic pyelonephritis and pyelitis.

ft ft Group II All cases diagnosed as "scarred,”

"markedly scarred," "grossly scarred," and "scarring of the

kidneys." Cases diagnosed as "fine scarring of the kidney

with Kimraelstiel-Wilson Disease" and "focal scar of the

kidney" were not included. There were approximately three

cases in the former category and three in the latter. The

sex incidence was approximately one to one.

The scarred group (Group II) was included in this

study of chronic pyelonephritis so as to avoid the pitfall

of individual variation in pathological Interpretation and

* Autopsy numbers 12200 - 13780. (There were 5^ cases missing when all slips between 12200 and 13780 were counted. Therefore the series comprises 1,526 cases and not the expected 1,580 cases between numbers 12200 and 13780).

** To be referred to as "scarred kidneys" throughout the rest of this paper.

_4~

thus not overlook what others might consider changes compatible

with the diagnosis of chronic pyelonephritis.

The autopsy protocols were used at the source of in¬

formation for the pathological description of the kidneys

and genitourinary tract. From the clinical record, the past

history of genitourinary disease, diabetes, and hyperten¬

sion, was obtained, as well as the occurrence of a family

history of cardiovascular disease.

Information was collected on urine cultures, i.e.,

positive and negative and quantitative bacteriology, Hoivever,

the records of these cultures were for the most part in¬

adequate and only a minority had been quantitatively evaluated.

Therefore, the urine culture data is probably not valid in

the group considered "positive.M Sterile cultures ("negative")

are considered valid irrespective of the application of

quantitative techniques.

From Group I (chronic pyelonephritis and pyelitis)

all cases with evidence of primary genitourinary tract

abnormality were eliminated. This consisted of cases with

prostatic hypertrophy (including prostatic carcinoma),

urethral stricture, extraparenchymal stones (those below

the renal parenchyma -- in the calyces, pelves and ureters),

carcinomatous obstruction, cystocele and exstrophy of the

bladder. The remaining cases of Group I, those without

evidence of primary genitourinary tract abnormality, were

further studied for evidence of obstruction by looking for

trabeculation of the bladder; no additional cases were found

by this technique. Thus a group (Group I A) had been selected

for further study which contained all cases of chronic

pyelonephritis in the absence of primary genitourinary tract

abnormality.

Prom Group II (scarred kidneys), cases with N.P.N.’s

greater than 85 mg. % and/or contracted kidneys (one or both

kidneys weighing less than 100 grams, or described in the

pathological protocol as ’‘small") were selected. Again, as

in Group I (chronic pyelonephritis) cases with evidence of

primary genitourinary tract abnormality were excluded from

this group of cases with N.P.N.'s greater than 85 mg. %

and/or contracted kidney. Thus a group (Group II A) of cases

with significant renal disease in the absence of urinary

tract obstruction In which the pathological diagnosis of

chronic pyelonephritis might have been overlooked, was

selected from Group II (scarred kidneys) with N.P.N.’s

greater than 85 mg. % and/or contracted kidney.

Groups I A and II A were studied in detail. The

frequency of findings such as hypertension, positive and

negative urine cultures, diabetes, N.P.N.'s greater than

85 mg. /, past history of urinary tract infection, family

history of cardiovascular disease, were correlated for each

sex within each group (see Tables M,?).

-6-

Histologic Classification

The microscopic slides of the kidney sections of

patients diagnosed pathologically as chronic pyelonephritis,

pyelitis and scarred kidney, were reviewed with Dr. Lawrence

R. Freedman without prior knowledge of the pathological

classifications or sex. They were histologically classified

into 6 groups as follows:

1. Non specific scars (N.S.)

2. Minimal focal pyelonephritis (M.F.P.)

These were kidneys with lesions similar

to those described as "typical focal

pyelonephritis" present to a lesser degree.

3. Typical focal pyelonephritis (T.F.P.)

These kidneys had large focal scars, crowding

of glomeruli, some of which were hyalinized,

dilated and atophic tubules with and without

colloid, casts, interstitial fibrosis, and.

infiltration with round cells, separated by

areas of normal kidney.

4. Diffuse pyelonephritis-like scarring of the kidney

or diffuse scarred end-stage kidney (D.E.K.)

These kidneys contained most of the elements

of the typical chronic pyelonephritis but they

were in such an advanced stage of disease

that the ability to make this diagnosis with

-7-

certainty might he questioned by some

investigators.

5. Pyelitis (Pye.)

These kidneys had. inflammatory changes limited

to the mucous membranes of the pelves,

6. No abnormality seen (No0)

The histological classifications were correlated with the

sex in each group.

-8-

RESULTS

Group I - Chronic Pyelonephritis and Pyelitis (Table 1)

1,526 consecutive autopsies at the Grace New Haven

Community Hospital from January, 1957 to January, 1959 were

reviewedo The autopsy group was composed of 57.4$ males and

42.6$ females* There were 97 cases (6.34$ of the total

autopsy series) with the pathological diagnosis of chronic

pyelonephritis. This group consisted of 63 males (65$) and

34 females (35$)® 5 cases (0.33$ of total autopsy series)

had the pathological diagnosis of pyelitis. Two were males

(4o$) and three were females (60$). Thus the total group of

chronic pyelonephritis and pyelitis (Group I) consisted of

102 cases (6.67$ of the total autopsy series), of which

there were 65 males (63.7$) and 37 females (36.3$).

■ From Group I all cases with obstructive disease of the

genitourinary tract were excluded. This amounted to 49

cases (48$) of the total chronic pyelonephritis group), of

which 4o were males (81.6$ of the males of Group I) and 9

were females (18.4$ of the females of Group I). Thus it

can be seen that many more males are found with primary

abnormality of the genitourinary tract in association with

pyelonephritis than are females. Prostatic hypertrophy,

including carcinoma of the prostate, was the greatest single

cause of primary genitourinary tract abnormality. It was

TA

BL

E

1.

CH

RO

NIC

PY

EL

ON

EP

HR

ITIS

AT

AU

TO

PS

Y

AT

G.N

.H.C

VL

JAN

UA

RY

, 1957

- JA

NU

AR

Y,

19

59

„Q_ s

V5.

CQ ©

0

VO O o CM nt O o CO 4> o o o o « 9

CM *m o VO co o O o o o CM cm VO CM H VO O o vn o VO,

H fH pH

o ■£" cm CN- On CM H rH CM rH CO VM CM CM CM M3

o o £>- VO O o CM O 9 » <9 9 9 9

ev¬ vn, o CM rH o O O O o M- en, vo VO co ©

rH O tH

vm o rH

H-

CQ 0 VO CM CM VM o CM CM CM CM rH vn, fH IM- VO VO Hj- CM CM a5 00 S

Ht CM O- O o O o O CM cm VO o CM O O CM CM fH CM CM O

9 ♦ <3 9 O » o O 9 o 9 O VO o VO co en, ■d- o CM CM CM CM CM CM

-£■ VO fH rH vn,

H VO o- vn, CM c\ CM CM vn, rH pH VO rH rH CM 05 CM Ov O -d- CM vn, -P VM r—I o

Eh H 0 O c (D CQ L cO

CQ

P 42 bO -H P £ £ •H •H £ £ X3 ft £ 0 CQ H £ <H £*5 O o P P £

rH •H *H 0 rH rH >5 0 05

CM >> e >5 CM in 43

© O SH £ rO £ O £ £ 43 £ O 05 05 P

£ CQ CQ P 0 0

•H o •H O p,P P P 05 £>s 05 ■H CQ H £ S3 P £ 0 £ H m j£ m co 43 o o Of 05 *H CXD •H £

CQ CD O P 0 P CX- 0 £ £ O 05 •H o rH rH O +3 o CQ 1—1 tH 0 H CQ 0 O, 0 < >i 0 £ O O O CM >5 Gj £ P Pm 1 CM E CM £ CQ •H < o •H H S3 O £

•H P o5 *H CX 1—1 c *H CX £ Oj o rH O p £ 0 O £ o 42 t>S £ 43

Eh O CM o O

0 43 -P

£ >5 •X p

£ •H £ O CQ H

£ •H «H H ■H 05 O CQ P CO P 6 ■H £ O E *H £ P 05 £ >s £ O O O £ O 42 43 £ £ P 0 O £ CX 43 £ o CQ S £ 0 0 CO

0 P P L 0 tO £ £ CQ £ O H £ ■£ O P £ rO <3 c3 CO cO rH O P o o o ex H 0 05 0 H «H H co CQ >s £

■H Ul tO > CQ £ CM Eh £ £ £ H © P <H P O 0 0 > X O O t© CO P cd P, 0 •H

05 o © 0 >5 £ O H S P £ £ rH 43 O 05 o £ © £ •H 0 ex £ J>> £ £ CO P P H O O 42 £ 43 £ 0 O £ o £ O CO P o £ £ O p P 6 0 £ 0 £ £ H CQ CQ 9 »H £ 0 L> P CO >s X £ £> O C CO O O W <o ex

H O

O £ o

-10-

found in 32 cases comprising 65.2# of the cases with primary

genitourinary tract abnormality. Extraparenchymal caluli (those

calculi below the renal parenchyma - in the calyces, pelves,

and ureters) was the next largest group. There were 6 cases

(12.1#), composed of three males and three females. Third

in order of frequency was carcinomatous obstruction of the

urinary tract which was found in 5 cases (10#). Two were in

females/ three in males. Fourth in order of frequency was

urethral stricture of which there were two cases (4#) both

in males. The remaining factors were each found in one cases

stricture of the vesical neck, aberrant renal artery causing

ureteropelvie obstruction, and cystocele, which were all

found in females, and exstrophy of the bladder found, in a

male.

Group I A » Chronic Pyelonephritis In the Absence of Primary

Genitourinary Tract Abnormality (Tables 2, 3_)

There were 53 cases of chronic pyelonephritis in the

absence of primary genitourinary tract abnormality. This

was of the total number of cases of chronic pyelonephritis

diagnosed at autopsy at the Grace New Haven Community Hospital

from January, 1957 to January, 1959® Of these there were 25

males (47.2#) and 28 females (52.8#). Applying the Chi square

formula to this group, one finds no significant difference

between the ratio of males to females at the 5# level. Further¬

more if one assumes that the male to female distribution in

-11

o Ph G Ph Ph Ph Ph Ph Ph Ph Ph Ph

EH o fo Ph Eh Ph Ph Ph Ph Ph Ph O «H Eh Eh Eh Eh Eh Eh £ S <3 s CP Eh

X o * CP ^3 *0 * O mo O mo o o o o o o o o o mo mo mo O O <3 vo C- P-5>- MOvO CM CO co oo p- CM <o- rH rH vo -p VO MO is x is iH Cm rH pH CM rH i—1 rH rH rH rH rH rH rH rH i—1 H CP Co o o & Eh ° 0 H bO «h X SS Q W o

0 pH «m 0 o G HO 4 » <9 o

«H rH CQ CQ CQ CQ © w G G O O O o bO o G> O P^ P. PH Pi G

w tn * <9 - CQ <D Eh <3 •Eh

Ph CO W 0 ffi X EH rp is -p- o CO CO O OV CM

Ph VO Ov p- VO CM co O 3S is pH rH rH & H * 4) ro

O o Oh &4 {—i 40 -P <T* =H ra G O

H •H d <3 0 9 O ® 40 © CP PP 0 > X HO X -P 40 40 X « 40 CP CP O £> P P (P 4h P V} Ph O O o o o w e o D S 0 -P -P 40 40 b) 40 g O Ph Ph o X o X o o 0 O i-Q W _ e c G G G G G

© pH CO Ph w

t-Q o < H S3 is O is M H

ffi L O X

. M < x M <d

Ph P3 G> O o is W CQ O <3

rO

O

ctf

CQ CQ

• Ph tu cp

o ICO

MOlO ■cr b- f-i I

CM x>

: t* Ph

0 0 O bO 03

<3 CP

co tv-is

VO co vo is

o co

CM -P- is

Ov VO S

X

co vo is

VO vrv:

vo C'- vo:

•H

&

bO

0

"O

CM

a CQ

-I X 0 CQ rH Pj ro CM co ctf O CM nt 00 S 40 CO co rv

G CM CM CM <3 rH 1—i rH

CO VO rH rH ot O 4j- rH vo 00 C0 O CM CM CM 0^ rH rH ■rH rH

9

O

o

0 MO rH co rH ot • CM co co cd CO co CO rH rH rH *

(conti

nued

on

next

page)

TA

BL

E

2.

GR

OU

P

IA

CH

RO

NIC

PY

EL

ON

EP

HR

ITIS

IN

TH

E

AB

SE

NC

E

OF

GE

NIT

OU

RIN

AR

Y

TR

AC

T

AB

NO

RM

AL

ITY

IN

MA

LE

S

(conti

nued)

12

o X X X X X X X Ph 0 « £ X M X W X w x fin >>

*H O

s

e Q Eh Q Eh o Q Eh P-f

• rp ° o o O O O O UV, O O uv o v> o o O vv X *H p r-l rH CM CM 0-0- 0-00 00 (N- o c- 0-0 VO vv

X x H rH pH rH 1—1 rH rH pH rH

o

Q

<m a) C *

•H H bD P 3 C X O

m • O bD P, £

bD £

0 X H • Eh

X 1=)

• X oo o OV O rH o UV O •H rp Ph CO C- o uv CM rH ov o n3

X OV OV C\! rH rH ov £ 0 p. X

® -P <n P £ a © w 0 C X o X X 9 0 •H 0 > 9 -P a -P • X P 0 x x o Cm X X X 9 X to

« o o Cm o e © o O « 0 bD -p bD -p bD bD p 8 X X 0 o X 0 X o 0 0 o

X £ £ £ c £ £ c Hr 9

•H

©>> •

X • X ojo OjuV o jo o|o CO o o o o|o

X X oo Ko X CO -3- |0V nb o Cm ov Cm wo rH | CD JrH nh rH CM rH rH |H O

bn

« * X 0 X X

• e* X

x x x x Cm

0 0 O VO ov fcuO 0 IN-!S OVX < x

CO OVX

o (H |2

ov ovX

VO vo X

VO rH |S

oo cm^

o- VV 3

0

9

rp

Hfc

0 CQ rH P ■ct Ov VO C\i ON 0 O ov W VO CM W S P w W w HT CM

£ ov ov ov CM CM <tj i—1 rH rH rH rH

a

9

rO

-a- Cm Ov Ov CM W O CM a

ov ov CM OV 0 CM CM OV ov i—! X rH rH *

(conti

nued

on next

page)

13

© o Pw X Ph X Ph Ph <*H £h pH pH Ph W Ph Ph

EH o Eh EH Eh Q Eh S

X Eh

Ph X Hd ° o o O O o o o o VT\ O O O < ■H -p VO On O—ct o o ovco CM CO ev £>- E X 5s rH X c\] <M rH X X rH rH rH H Ph X O • E Eh hD 05 H -H X E W o

Q

Ph • 0 O «M C -P

•H s—1 w ?H 2 o X O E w CO O 9 E (D E H < 4 Eh

Ph E W E Eh 4 E CM U~\

X Ph £>- i—1 S E CM H

CO O * -P H P 4-3 5h Eh 0 w o3 <! © H 3 ■H 0 > X cp a E E O © E *H Ph -P W C B <s E O CCS fc>0 o o Ph Ph 0 X X ' e c W X CO

o < H S o E E Ph O E E g H

O X Eh « « Ph

- M 05 E E < X M < E^

X

s Ph « X O O E 0 ffj E 0 0 cx VO 00 -X O < ED 05 OvE vO S E\E CM

<J Pm

X

(T\ EV -x e

©

•H

E

bl)

«w

0)

9

TO

E

a =ffc E < X Eh 0 CO

X ft vr> VO E rH co E- 05 O ev X VA VO o X S 4-3 -X vo X vrx VO

PS E E E EV Ex E\ C i—1 i—1 rH X X X

05

*

see

Ap

pen

dix

-14-

Eh O < ca EH

a

§ M CQ

O EH H S W O

An o M O S W C/3 CQ <

w

£h

X M

cn H Eh H CQ ffi Ph M S3 O i-Q GO w w >H hJ p-t <q

s o w H An S O X g H

O X Eh

. H < X

o P X Ph Ph X X Ph X X O W Ah Ah Ah w w Ah W w m

«H Q Eh Eh Q Q Q Eh Q Q X s

«o • unun un o O O O O ❖

MN«N O UN o o

• P B O o o

<H 4-3 X O- e on ON o MNMN ON O ON 00 CM UN O CM ON CM X ^

o p

Q

rH f—1

X

iH rH rH C\i rH

X

rH rH

X

O rH CM CM

hO

o 0 o X C -P * 0 o •» » o • •

•H pH TO TO TO TO TO TO TO TO U P o o O o O O o O by X o p. p. P. p PE P. p- Pn p

® « 0 X H

•EH X X X X X Ph 1=)

• X JN- o ON P- CM o CM o P- ON •H X Ph ON H± CM rH ON NO CM UN

X rH CM CM rH rO s 0

0 « PH

O HP -P c O o Pj <4 TO P > X X X X X rC 0 9 .Q

*H 0 O O o -p* 4-> a 0 0 TO

X 0 Cm & P X

« • • o O

o s bO to 4-3 -P be s 0 P; Pr. o SH

0 c*

0 C“!

o c-1

O r>

0 r~*

b 8

CQ e

P-: 0

CQ

fl3 E A:

o o 43- o»

o o CM rH CM H

O O On i—I r—I H

O CN- rH

UN O O O rH CM

olo NOON rH I

OjO o NO rH

UN X)

H C <B O X X X X S Ph PQ

Ph Pi X> o o x CQ CQ O <3 0

0 o o rH O 00 o hQ- ON •4t 43- NO 6o 0 MNS: P~iS ■3- ^ »4N^ nC i2 NO ^ oo :s O-^g NO 13

« < CQ ON

a PQ

X Eh 0 TO

r-H Pj ON 03 ON ON ON 03 CM NO MN UN 0 O o- ON ON CM O un O pH UN ON S -P CM -4 o- 00 O O i—I rH CM ON 0 0 CM CM 04 CM O'! ON ON ON ON ON

Ah <J i—1 i—1 i—1 rH rH i—! rH rH rH rH

•H

O0

0

&

et o

0

$

(continued

on

nex

t

page)

15

Eh O

Eh

X

§

H P3 X O X H X

« o «H Sh Ph Ph Ph X

o X Ph X X <H X Eh X X X

•

X P •

*

vo O O vo O O VO vo •H -P coco COCO rH rH CO CO X X rH r-( rH rH rH rH

o

• P bO CO

«H

p X

Ph X X X 0 Ph X X X X X X Eh Eh Eh Eh X Eh

o o =5=

VO vo o o O VO vo vo VOC0 CM VC 00 c CM f—1 vo O CM CO too- CM X (—1 rH rH CM X rH rH

X

X o 9 0 ®

PGP X •H pH o P 3 X X O X CO o <a

X 0 X H < ° Eh

X X X X Eh O X

X X X X H

X CO 0 0 a

H 3 O-PHC Eh C CQ Sh > H <H •H 030 X P X 0 X C X X O 9 X O E X - 03 X: O X a X CO ffl X X

Ph <

o x 9 hH X * X; X X O X PQ P3 M SC

. M n 0 9 0 <! p 03 X X H < <9 9

S X X X M x o o x X PQ

<-

O < 0 0 O bO 03 0

<r\ <J X

« • © o o a

co CO CQ CO CO CO o o O o o o X p< X X. Ph X

x X X

-=J- -=3- -3" co

vo ro cm vo

-=3- vo VO CN-

vo CM

O n3' vo to VO CO

X •H

*0 G <v

X a <

X 0 X 9 X o X © X 0 <9 p 9 P p p 0

X p Gj X X X to o O o o

© 9 8 bO p bO P p p 0 0 X o 0 o X o O c G C G G G •> o

•H

O O XIO 00 o CM O o o o CM X CM kO o Cv- O o CO sO VO CM rH 1 <—1 CM X X 1—1

o fe CO »

o!o VO O- H|

o o O-Ov X

op CM b> CM H

£

06* <9

bO

X X X X X o

0

-3- VO vo :s

nfr o-x

O-

o-s o- VO^

vo ts-X

O- C'-X

vo vo x

OV VO X

X

CN-X

<o

*0

a CQ < Eh <D w

x X vo VO co 03 o vo vo o E P CM vo tN- 0 3 CM CM CM X <3 X i—i X

CM o t>- vo O- x- CM £>- CO o\ X CM CM CM CO CO X X X i—1

G

«=* O

X

CO X vo ©V

vo o vo e CO o- CM CO CO CM CM X X X *

(conti

nued

on n

ex

t page)

rt

<*

-16-

o •H ?h 0 0 PH Ph Ph Ph

O X Ph Oh Ph Xfl fc Ph Ph Eh EH Eh X Eh

s

Eh O o ©

<J X D • PD «H Hp

EH X X

X Ph •

< • ^jD

X bO 03 H •H M Q X O X o <D ® H X C P X X rH W G 3 O X O

X o /> »

<D X H w * Eh o X X X w CO X <* X <3 X X

X w X Eh © o

O p P <3 X^ CO U > H X •H (35 O

<D X 0 CO 3 X M C ©

Eh *h E • H P 05 X w c (L

X O CQ X G <r H — X O X co 9 O w w X X X X ©

x <c X X

o X H fc X o X © © o

X H 05 X X X © *

o x X PQ Eh *r

j H < X m <;

S 0 Ph M (DO DO PQ CD OX <xj M ID PQ O C

P X &

o o O O O vx cx o o o o o o O VX Dr vo X X vx o\ X X O CO COD CX VX X rH X X X c x X X CM X H X

X

o © 0 CO m CO o o o X X pH

><:

iH .a-

X- O- CO cx vr\ cx CM

X X p p X X O O

X p X O

-P -P o o c s

P o c

o o o o o jo o X x- -D x- X j~X 1—1 X X CM (X X

X X X

o vo X

00 co x

o

P-X cm o-D

ON VO X

cx X-X

CM vo X

VO 00 X

8 I

•H

X

oO

Cm

0

X

o

©

(X t>s

P4 0 CO X Ph vo Ov vo

i-4 X

05 O o -D 1—1 -D 6 P CM CM X X

< 0 3 CM cx (X (X X X <5 X X X X

€>

X

in o VO, vo CM co CM vo o cx cx -D -D 0 cx cx (X cx X 1—1 X X ❖

see

Appendix

-17-

the general population is 50:50, one finds no significant

difference between the autopsy population and that of the

general population at the level,.

The frequency of the following factors was studied

in the males and females with chronic pyelonephritis in the

absence of primary genitourinary tract abnormality (Table 4).

Hypertention, family history of hypertension, heart disease

or cerebrovascular disease, past history of diabetes,

finding of positive and negative urine cultures, N.P.N.'s

greater than 85 mg. %t presence of contracted kidney (those

weighing 100 grams or less, or being described as "small''

at autopsy), past history of urinary tract infection, and

history of catheterizations and pregnancies.

Hypertension

Of 25 males, 6 had a past history of hypertension

and two additional cases had diastolic pressures greater

than 100 ramo Hg. on their las t hospital admission with no

past history of hypertension noted in the chart. Thus 8

men, or 57^ of the 14 men on whom blood pressure inforraation

was obtained, had hypertension.

Of 28 females, 12 had a past history of hypertension

and three had diastolic pressures greater than 100mm. Hg.

on their last hospital admission, with no past history of

hypertension noted in the clinical chart. Thus 15 women,

or 62.5$ of the 24 women on whom blood pressure information

18

TABLE 4* CLINICAL AND PATHOLOGICAL CORRELATES IN CHRONIC PYELONEPHRITIS IN THE ABSENCE OF OBSTRUCTION (I A)

Males % Females %

Total

P.H. tB0P.a° 8 of

25

14 57.1 15 of

28

24 62.5

Fam. Hist.c *

Negative 6 of 14 42.8 5 of 17 29.2

'fr BP 5 of 14 38.4 3 of 17 17.6

CVA Heart 4 of 14 28 o3 10 of 17 58.8

Diab. g* 3 of 25 12.0 7 of 28 25.0

f. Urine Cult.

Positive 5 of 9 55.5 17 of 18 94.5

Negative ■ 4 of 9 44.5 1 of 18 5.5 do

N.P.N. greater 85 mg. % 11 of 18 63 *4 7 of 24 29.I

Contracted kidney 6 of 23 26.1 11 of 27 40.8

P.H. U.T.I. e° 0 of 25 0 9 of 28 32.2

HISTOLOGIC CLASSIFICATION lo

Males % Females %

N.So 0 of 24 0 2 of 27 7.^1

M.F.Po 3 Of 24 12.5 2 of 27 7.^1

T.F.P. 15 of 24 63.0 14 of 27 51.9

d.e.k. 5 of 24 20.4 6 of 27 22.2

Pye. 1 of 24 4.1 3 of 27 11.1

No. 0 of 24 0 0 of 27 0

* a., c„9 d.s e03) f.,g., 1., -- see Appendix

-19-

was obtained, had hypertension.

Family History of Hypertension, Heart Disease, or Cerebrovas-

cular Disease

Of the 14 males from whom a family history was

obtained, 6 (42.8$) had a negative family history of hyper¬

tension, heart disease, or cerebrovascular disease. 5 (38%)

had a positive family history of hypertension; and 4 (28$)

had a positive family history of heart disease or cerebro¬

vascular disease. Thus 66.7% had a positive family history

for cardiovascular disease.

Of the 17 females from whom a family history was'ob¬

tained, 5 (29/0 had a negative family history for hyper¬

tension, heart disease, or cerebrovascular disease; 3 (18$)

had a positive family history of hypertension; and 10 (39%)

had a positive family history of heart disease or cerebro¬

vascular disease. Thus 77$ of women had a positive family

history for cardiovascular disease.

Diabetes

Of the 25 males, there were 3 cases of diabetes (12$)

and of the 28 females there were 7 cases (25$).

Urine Cultures: Positive or Negative

Of the 9 males who had urine cultures done, 5 (53%)

were positive and 4 (44$) were negative.

Of the 17 women who had urine cultures, 16 (94$) were

-20-

positive and one {6%) was negative0 These positive cultures

were difficult to evaluate since quantitative studies were

performed on only a few. The negative cultures, however,

are considered to have been properly obtained0

N.P.N. Greater than 85 mg, %

Of the 18 men who had N.P.N. reported, 11 (63.^)

had N.P.N. greater than 85 mg. %% and of the 24 women on

whom N.P.N.'s were recorded, 7 (29/0 were greater than

85 mg. %.

Presence of Contracted Kidney

Of the 23 men on whom kidney size and weight were

obtained, 6 (26%) had contracted kidneys (one or both kidney

weighing 100 grams or less, or described in the pathological

protocol as "small").

Of the 27 women on whom information on kidney size

and weight were obtained, 10 (37^) had contracted kidneys.

Past History of Urinary Tract Infection

Of the 25 males, there was no record of the diagnosis

of urinary tract infection ever having been made. However,

one male (12259) had "frequency" in 195^ and alpha street,

was obtained on urine culture. This, however, was not

quantitatively evaluated. On his last admission the culture

was negative. There were several other cases with symptoms

which were difficult to evaluate. They are case 12323 --

dysuria and dribbling, 12374 -- frequency and nocturia, and

-21-

12259} 13209 -- nocturia, however, the symptoms of these

cases were not considered sufficient evidence to state that

the patient had a urinary tract infection.

Of the 28 females, there was a history in 9 (32%)

of urinary tract infection. One of these, 13102, was

diagnosed as cystitis; one, 12665s was diagnosed as "chronic

urinary tract disease"; and the remaining 7 were diagnosed

as having had pyelonephritis at some time in the past. As

in the male group there was one female case with symptoms

which were difficult to evaluate, 132?5 -- frequency and

nocturia.

Catheterization

Information on this is difficult to collect but it

appears that of 18 males, 5 males had single catheteriza¬

tions. One male had an Indwelling Foley catheter for an

undetermined amount of time. Of 23 women, 12 had single

catheterization at one time.

Pregnancy

Of 28 women, there was a history of at least one

pregnancy in 11 women. In three cases there were no

pregnancies; and in 14 cases there is no mention of the

patient having been, or having not been, pregnant.

Pregnancy and Catheterization

Of 28 women, there is a history of 1? women having been

pregnant and/or catheterized at some time in the past.

-22-

Group II - Scarred Kidneys (Table 5)

Of the 1,526 consecutive autopsies, 66 cases of

scarred kidney (4.3$ of the total autopsy series) were

found* 39 (59.1/0 were male and 27 (40.9$) were female.

In order to examine those cases with significant

renal disease in which the pathological diagnosis of chronic

pyelonephritis might have been overlooked, scarred kidneys

with N.P.N.’s greater than 85 mgc $ and/or contracted kidney

were selected* There were 26 cases (39.4$ of the total

scarred group); 14 were men (53.8$) and 12 were women

(46.2$); from this group all cases with primary genitourinary

tract abnormality were excluded. This amounted to 7 cases

(26.9$ of the total scarred group), of which 5 were male

(71$) and 2 were female (28$). As in the chronic pyelo¬

nephritis group, the percent of males with primary genito¬

urinary tract abnormality is much greater than that of

females and again, prostatic hypertrophy (including carcinoma

of the prostate) was the greatest single factor of primary

genitourinary tract abnormality. It was found in 4 cases

(51$). Urethral stricture was found in one male and one

female and carcinomatous obstruction of the urinary tract

was found In one female.

* Scarred kidney includes all kidneys with the pathological diagnosis of ’'scarred,'’ "grossly scarred.," "markedly scarred," and "scarring of the kidney(s)."

-23-

TABLE 5. SCARRED KIDNEYS AT AUTOPSY AT G.N.H.C.H. JANUARY, 1957 ~ JANUARY, 1959

Total % i Hale of /° Female %

Total Autopsies 1,526 8 ?6 57.4 650 42.6

Group II - Scarred Kidneys 66 4.3 39 59.1 2? 40.9

Scarred kidneys with N.P.N. greater than 85 mg. % and/or contracted kidney 26 39.4 14 53.8 12 46.2

Scarred kidneys with N.P.N. greater than 85 mg* % and/or con¬ tracted kidney with primary G U tract abnormalities 7 26.9 5 71.5 2 28.5

Prostatic Hyper¬ trophy (in¬ cludes carcinoma prostate) 4 4

Urethral stricture 2 1 1

Carcinomatous ob¬ struction 1 1

Group II A - Scarred Kidneys with N.P.N. greater than 85 mg. % and/or contracted kidneys without 1° G-U tract abnormality 19 73.1 9 4y .4 10 52 06

-24-

Group II A Scarred Kidneys With N,P,N. Greater Than 85 mg, /

And/or Contracted Kidney in the Absence of Primary Genito¬

urinary Tract Abnormality (Tables 6, J)

There were 19 cases of scarred kidney with N.P.N.'s

greater than 85 mg. / and/or contracted kidneys, in the

absence of primary genitourinary tract abnormality. This

was 73.1/ of the total number of cases of scarred kidney with

N.P.N.'s greater than 85 rag. / and/or contracted kidney.

Of these there were 9 males (4//) and 10 females (53/).

Applying the Chi square formula to this group (Group 11 A)

one finds no significant difference between the ratio of

males to females at the 5/ level.

The frequency of the following factors were studied

in Group II A (see Table 8). Hypertension, family history

of hypertension, heart disease or cerebrovascular disease,

past history of diabetes, the finding of positive or negative

urine culture, N.P.N.’s greater than 85 mg® /, the presence

of contracted, kidney and past history of urinary tract in¬

fections .

Hypertension

Of the 9 men, there was hypertension in 5 (55/)® Of

the 10 females, blood pressure information was only obtained

in 8. Of these, 6 (75/) had hypertension.

TA

BL

E 6

. G

BO

UP II

A

SC

AB

BE

D

KID

NE

YS

WIT

H N

.P.N

.'s

GB

EA

TE

B

TH

AN

85

mg*

%

AN

D/O

B

CO

NT

RA

CT

ED

KID

NE

YS

IN

TH

E

AB

SE

NC

E

OP

GE

NIT

OU

RIN

AR

Y

TR

AC

T

AB

NO

RM

AL

ITY

IN

MA

LE

S

-25-

•H G X P-< X Ph Ph X X X Q H X H X X H XI m X

s X gr Q EH EH O Q X s

* Hi* X'd • -H- O O O O co O co O CO 6 O O CO o o o o

•H -p On ON C\! CM XCM co o- On £>~ O X COCO X CM cO-H X is X X pH O CM X X i—! X X X

O X

° CS X

Q

» CD 9 9 <M G -P W CO

•H i—i QD o GO o G 3 X O

G X C X

9 a <D 5C H

• EH X Pi X

° X X On On X CO X X X '■o X X CO X- o CO X On X

X CM CM X

o 0 o x x < o

CO X > 9 0 o 6 ® 9 • o X x «3 O X -P X 4-} X X -p 4-> 9

X 0) X X X X X X X X X X o o o o o o o Q

S X X X X X X X X GO G3 o o o o o o o O 0) X Pi G C G c G G c G G

cq

° o jo X P-i iN-[X

W X jrH

O O O X I—I

o jo o wb x CM JrH i—i

o o jo On <r\h-

cm H

o jo XPO I—11

coho _3- o -H to o x X | rH

olo £

to

• ® P' ( GS X PQ

Ph*^

X X X X X Cm

<li

CD CD O CO co On ON rH 0- X X CM GO CO MO is: x is x is X' is X- 53 CN~is x is o-is X 3 » < Pd

<d to X CM X CM o- o CM CM -H X

o

e X

0*

0 cO O X X X X CM X X X H- a S X X On On o ON X X X o-

3 CM CM CM X CM X X CM CM * < X i—1 X 1—1 i—1 X X X X

see

Appendix

TA

BL

E

7,

GR

OU

P II

A

SC

AR

RE

D

KID

NE

YS

WIT

H N

.P.N

.'s

GR

EA

TE

R

TH

AN

85

mg.

%

AN

D/O

R

CO

NT

RA

CT

ED

KID

NE

YS

IN

TH

E

AB

SE

NC

E

OF

GE

NIT

OU

RIN

AR

Y

TR

AC

T

AB

NO

RM

AL

ITY

IN

FE

MA

LE

S

26

«H O SQ Pm PQ PQ PQ PQ 0 X a Pm Pm Pm m tQ Pm o w

•H Eh Eh Eh X X § Eh X Q s

o

O * X * X X » Mb Mb o o O O o o e Mb o o Oo o o IAN O Mb

•H -P Ob 00 rH ft rH O On On O Mb O CM Obft CM rH O rH X S rH rH rH CM O H rH rH CM CM rH rH rH rH

hO X

G5 •H Q

X c~

® 0 « Cm S3 -P O <s> ®

•H rH CO oo W w oo SQ 3 o o o o o X O ft ft ft ft ft

0) X H •Eh X

PQ X

• IS JN- CM ra PQ cm cb

S

o o

■P -P ft 02 Pi > X •H C5 O ® ®

PQ 4) X

Cm Cm

0 O 9

s bO bO CO <D <D X PQ

PQ kr

S3 S3

X

0b NO VO Mb O pH

rH rH

•» ©

X X -P •» X Gw o

o ■p bO o 0 S3 a

<\i cb

-P

X O

-P X o

X X

ft CM NO o On ft rH CM rH

o X X -p X o

-p -p -p o o o S3 S3 S3

o

02

8 8

•H

PQ PQ

• • Pm 05 Hi PQ

PQ ^

SI

to UbjO o o o jo Ofb o jo o O Of' to cm to ft ON CM jO o-to OpN NO ON Of 1 H| i—1 CM H rH| CM 1 rH Obf

X X X X X X

bQ

Cm

<D

0 0 o O Ob CM e- CM Mb H O O CM

O X

bo 05 VMS £b- Is Mbs o-X 0\S O-S 00 IS ft S MbS ft X ft X

X 0 00 rH Pj O CO 00 ON Ob CO CM ft '•b NO

© a

s* ©

X

05 o rH ft CM ft- rn, NO ft CO H NO 9

S P 0b ft {>- NO Mb 1—1 0b Ob O H cd 0 3 CM CM CM CM Ob Ob Ob OH cb Ob X ft X rH i—1 rH H H H H i—i H *

ee A

pp

en

dix

-27-

TABLE 8, CLINICAL AND PATHOLOGICAL CORRELATES IN SCARRED KIDNEY GROUP II A

Males % Females %

Total 9 10 a .

P.H* 'TB.P* 5 of 9 55.5 6 of 8 75 o0 c.

Fam. Hist.

Negative 1 of 1 100 * 3 of 6 50.0

1\B.P. 0 of 1. 0 0 of 6 0

CVA Heart 0 of 1 0 • 3 of 6 50*0

Dlab*

Urine cult*

1 of 9 ii*l '1 of 10 10*0

Positive 2 of 4 50*0 5 of 5 100.

Negative 2 of 4 5o*o 0 of 5 0 d*

N.P.N. greater 85 3

» ON

o

»-+>

00

75 o0 5 of 9 55 o5

Contracted kidney 6 of 9 66*6 8 of 10 80*0

e * 4 40.0

I

P.H. -U0T .1 „ 1 of 9 11.1 of 10

io HISTOLOGIC CLASSIFICATION

Males % Females a/ /o

N*S. 1 of 9 11*1 2 of 9 22*2

M.F.P0 2 of 9 22,2 1 of 9 11.1

t.f*p9 2 of 9 22*2 4 of 9 44*5

D*E.K. 4 of 9 44,5 1 of 9 11*1

Pye. 0 of 9 0 0 of 9 0

No* 0 of 9 0 1 of 9 11*1

* a *, cOJ dOJ e„, f., go, I*, — see i Appendix*

-28-

Family History of Hypertension, Heart Disease, or Cerebro¬

vascular Disease

Only in one of the 9 men was a family history obtained,

and it was negative for the above. Of the 10 women, 6 family

histories were obtained. Three were negative and three had

a positive history for heart disease or cerebrovascular

disease, ■

Diabetes

Of the 9 men, there was a history of diabetes in

one (11$) and of the 10 women there was a history of diabetes

in one (10$),

Urine Cultures: Positive or Negative

Of the 9 men, 4 had urine cultures. Two were positive

and two were negative. Of the 10 women, 5 had urine cultures.

All were positive. Once again, the positive cultures are

difficult to interpret since quantitative studies were

performed on only a few. The negative cultures however are-

considered to have been properly obtained,

N,P»N,fs Greater than 85 mg. $

Of the 9 men, N.P.N. was recorded in 8, Of these

6 (75$) had N.P.N.'s greater than 85 mg. $. Of the 9 women

on whom N.P.N,*s were recorded, 5 (55$) bad N.P.N.*s greater

than 85 mg. $„

Presence of Contracted Kidneys

Of the 9 men, 5 i55%) had contracted kidneys and

of the 10 women, 7 (70$) had contracted kidneys0

Past History of Urinary Tract Infection

Of the 9 men, only one (11%) had a past history of

urinary tract infection. Of the 10 women, 4 (40%) had a

past history of urinary tract infection.

Many of the figures in this section on Group II A

(scarred kidney) comprise very few patients and caution must *

therefore be exercised in drawing conclusions from them.

However, they agree with those obtained earlier In the study

on Group 1 A (chronic pyelonephritis) and it is felt that

they tend to confirm the general thesis that the incidence

of lesions called chronic pyelonephritis or perhaps due to

chronic pyelonephritis (Group II A) is the same in both sexes

Histologic Classification of Kidney Sections

The slides were reviewed without prior knowledge of

the autopsy diagnosis or sex for both the pyelonephritis

group and the scarred kidney group. They were histologically

classified into 6 groups as follows: Non specific Scars,

Minimal Focal Pyelonephritis, Typical. Focal Pyelonephritis,

Diffuse Pyelonephritis -like Scarred End stage Kidney, Pyeliti

No abnormality seen. (See Method for definition of groups).

-30-

a. Group I A - Chronic Pyelonephritis In the

Absence of Primary Gen11ourinary Tract Abnormality (Table 4)

Of the 24 men on whom microscopic slides of the

kidney were obtained, there were no cases of nonspecific

scars of the kidney0 There were three (12$) that were placed

In the category of minimal focal pyelonephritis. 15 cases

(63$) had typical focal pyelonephritis. There were 5 cases

(20$) with diffuse end stage pyelonephritis-like kidneys,

and one case of pyelitis.

Of the 27 women on whom microscopic slides of the

kidney were obtained, there were 2 cases (7$), with non¬

specific scars of the kidney. There were also 2 cases (7$)

with minimal focal pyelonephritis. 14 cases (5 2$) had

typical focal pyelonephritis and 6 cases (22$) had diffuse

end stage pyelonephritis-like kidneys. There were three

cases in the category of pyelitis. All three cases in the

histologic category of pyelitis were in agreement with the

cases of pyelitis diagnosed at autopsy. (It will be noted

that 5 cases were diagnosed at autopsy and only 4 cases, 3

women and one man, are noted in Group 1 A, since one man had

primary genitourinary tract abnormality and was excluded.)

b. Group II A - Scarred Kidneys with N.P.N.* s Greater 't'han 85 mg. $ and/or Contracted Kidney in the Absence of Primary Genitourinary Tract Abnormality (Table 8j~ ‘ ~ .

Of the 9 men, there was one (11$) with nonspecific

scars of the kidney. There were two cases (22$) in the

category of minimal focal pyelonephritis, and two cases

(22$) in the category of typical focal pyelonephritis 0 4

cases (44$) were diffuse end stage pyelonephritis-like

kidneys,

Of the 9 females on whom microscopic slides were

obtained, there were two cases (22$) of nonspecific scars of

the kidneyo One case (11$) was in the category of minimal

focal pyelonephritis, and 4 cases (44$) were In the category

of typical focal pyelonephritis. There was one case of diffuse

end stage pyelonephritis-like kidney, and one case (11$)

with no apparent pathology. Thus 4 of the 9 scarred males

appeared to have either minimal or typical pyelonephritis

as did 5 of the 9 scarred females.

It is felt that there were no significant differences

between the two sexes in the histological evaluation which

was carried out within the pathological groups selected for

study.

-32-

DISCUSSION

This study has demonstrated that chronic pyelonephritis

as seen at autopsy in the absence of obstructive disease of

the genitourinary tract occurs with equal frequency in males

and females.

In a review of the 1,526 consecutive autopsies at the

Grace New Haven Community Hospital from January, 195? to

January, 1959 there were 97 cases with the pathological

diagnosis of chronic pyelonephritis0 This overall incidence

of 6.34$ compares favorably with previous surveys reported

in the literature.

REFERENCE

Shure (39)

Eaaschou (32)

Jackson et ah (15)

Kinney and Mallory (20)

Keefer (1?)

Schreiner (37)

FREQUENCY OF CHRONIC PYELONEPHRITIS

2„5^ of 11,898 autopsies

5o6% of 3,6o? autopsies

9% of 4,425 autopsies

14fo of 1,000 autopsies

15-20^ of "all autopsies"

20/£ of random autopsies

In order not to overlook any cases of chronic pyelo¬

nephritis this study has also included in a separate group

(Group II) those cases in which a pathologic diagnosis of

"scarred kidneys" was made. This was done because the

etiologic factors causing renal scarring are not always

^33-

certain and scarring may be due to chronic pyelonephritis.

In the scarred kidney group (Group II) the male to female

ratio was found to be approximately one to one. From the

scarred kidney group cases with N.P.N.’s greater than 85 mg,

% and/or contracted kidneys were selected and analyzed

(Group II A), so that one might study those cases with

significant renal disease. Again, as in the chronic pyelo¬

nephritis group (Group I A), the number of males and females

were approximately equal, in the absence of obstructive

disease of the genitourinary tract.

In the literature opinions differ as to the sex

Incidence of chronic pyelonephritis at autopsy (Table 9).

This issue is greatly obscured since most of these investiga¬

tors did not rigidly exclude pyelonephritis in the presence

of obstructive disease (14, 1, 39$ 19)• Therefore, from

these studies one can get little idea of the true sex

Incidence of chronic pyelonephritis In the absence of ob¬

structive disease of the genitourinary tract. Three studies,

however, did delineate pyelonephritis in the absence of

obstruction. One of these (Likely et al,) is difficult to

evaluate since “nonobstractive pyelonephritis11 is not

defined. The remaining two studies (2, 32) where all of the

obstructive disease of the urinary tract is defined and

cases with obstruction are excluded, each have the Incidence

of two females to one male. These results are not dissimilar

from those in the present study showing an equal frequency

TA

BL

E

9„

CH

RO

NIC

PY

EL

ON

EP

HR

ITIS

AT

AU

TO

PS

Y

34,

CD H 03 V\ a VO o a 4- a a 6 H GO H a H co —p

CO <D 1—1 <D pH CO 03 O

0 ^—! rH o 0$ a Ov oo o a CM a a

S o VO H i—1 H CM P H H f—1 03 4 S R i—1 4 03 CM -3- -£T o CM VO CM VO

P CM Ov CM a CM CM O VO O H CM CM H

6 O E

4 0 P P P C O P -P >> 0 *H a o •H •H P 0 CO P s O a, O 03 03 P G

•H ♦ o o 0 0 o R CO -P o -p H «H p p R P CD o f—1 R 0 03 O 0 P P CO o R 0 0 >5 0 P CO 03 03 P >5 0 ftP H E CO 4

C O CD -P a'P -P 0 0 O 03 4 O o -P £0 0 0 O 41 CO *H 0 O

•H 03 4 G 4 P P co 03 H -P o c O •H R © 4 >s P R H O CO -H 4 H o O CO CO 0 H o 0 CD 0 6 a o H 0 ap O CO H CO -H <5 O X 0 £0 o p X 0 P 0) 03 H CO p 0 K3^ 0 0 p 0 0 CO R

CO G 0 0 -p Ph > O r a 0 4 CO 0 -P * •H 0 >s 4-0 o

<D -4- 0 cd o « <4 •P a 41 O 0 CO VO Ph o « E P 0 O a p P a b» cd O 03 P 4 03 R 0 P o O O ss 4 4 e o R P B e P vo 4

CSV >5 a o o rH p o ® 0 o 6* 0 P a4 pH •H 03 O co p O c H a O P> 03 p 0 X 4 a i—1 EDP CO

Cm Cm Cd 4h 0 o CO 0 o 0 *H o Cm 0 o p, o eo R O p 03 R O

03 o O P s p o 0 o a 0 P CO ° & Ph IS E -P PO o c p a E 4-^ £ © 03

P 0 R 0 EO co 0 P r o © co 0 « •H 0 0) «H •H rp 0 4 •H 0 ' c P a 4* <H 03 P 03 -P > 0 > 0 «H O 03 C Cm H £5 4 0 0 > 0 0 R •H 0 > 0 03 03 O O 0 a o 0 03 co H P-r PI «H Pd 0 CO *H co s CO od R G O -P H co ® 0 P CO CO 0 o H 0 X

>1 o >5 o 0 >> CO O 0 0 CO >5 G E 0 CO R CO X CO CO 0 R CO £0 0 co cd CO co X 0 P, P a 0 0 Pr a p 0 Q-i «H 0 O a a 0 CO CO O P o O O p o o s o o o 0

-P CO P -P -P O CO p 0 a p P 4P 0 CO R 4 R O 4- R a 4 CM R P VO CM R R O 4 0 c o < P CM 0 CM o CM 0 R CM H 0 <d P Eh G

CO p 0 -p o

H 1—1 H 4 a /-N 0 0 0 P H CM CM

Is •rH ®—■" a a P •R .—- g v_^

<D 0 P a P CO • O 0 a 0 1 H R R E CM c w 03 0 O O <D —' O^r P — t>a H •H 4 4 Ph co H 0 H 0 r—1 CM 0 P O G CD H dsi p 0 G 0 CO CO

Cm i—1 O P R Rd P 0 0 (D 0 0 0 4 •H <H 0 0

Ph m m CO i-l 14 Pd Pd

-35-

of males and females with chronic pyelonephritis in the

absence of obstruction.

To be certain that there was no histologic pattern

typical of one sex, the slides of the present series were

reviewed without prior knowledge of the autopsy diagnosis or

the sex, for both the chronic pyelonephritis group and the

scarred kidney group. The histologic changes seen within

the two groups did not differ significantly between the two

sexes.

The age incidence of pyelonephritis in males and

females was analyzed (see Figures 1 and 2) to see if there

was any particular difference between the distribution of

ages in the two sexes. The peak distributions were similar

but there were proportionately more males in the younger age

groups. The difference between these results and others

where there was a preponderance of males In the age group

over 60 years (28, 39) is most likely due to the inclusion

of prostatic hypertrophy in their series, and its exclusion

In this series.

The incidence of hypertension (diastolic pressure

greater than 100 mm. Hg.) was determined in the groups with

chronic pyelonephritis and scarred kidney in the absence of

obstruction (Groups I A and II A). In the former, the males

and females have a 57»and a 62.5$ incidence respectively.

Similarly in the latter, the incidence of hypertension for

males and females was 55.5$ ana 75$ respectively. It is

~3k-

flGE D\STR\&UT\OH \N GROUP Xft

CHRon\C LOflEPHRmS

□ MALE'S H=as

PEMPkLES

on LXJ cn <x o

cr U-) OQ z:

»Oi

«

\.

d» $ a* £ <*• ^ cT £cf* £ $

o-\o n-ao a.1-30 ai-no mi-so s\-<>o 6»-io

d* $. cf g cf £

~ll-«0 si-^o e\\-\oo

RG-E 1M VERRS

FIGURE #1

NU

MB

ER

Of

CR

5ES

-31-

RGE D\STR\fcvn\Ott Itt 6"ROUP HR SCftRRfcU KVDHE'VS

D MR^S

■ ftMftues n= \o

RGE IH ‘YEfiftS

FIGURE#2

-38-

apparent that the two sexes are approximately equally

affected. Since these groups are without matched control

patients, nothing definite can be said about the incidence

of hypertension in pyelonephritis„ However, it is of interest

to compare this data with that of others (Table 10)„

Since Longcope (21) first described the association

between pyelonephritis and hypertension and Weiss and

Parker (43) demonstrated the histological lesions in chronic

pyelonephritis which were associated with hypertension,

many have written on the relationship between the two diseases.

Unlike most investigators Bell (2) felt that hypertension is

seldom related to "uncomplicated chronic pyelonephritis" and

Goldring and Chasis (13) have produced evidence from which

they deduce that there is no correlation between the two

diseases. However most authors (Table 10) believe that the

incidence of hypertension is significantly higher in patients

with chronic pyelonephritis than in those without. The

evidence in the literature of an increased incidence of

hypertension in the presence of pyelonephritis is difficult

to evaluate due to the following factors:

1) Not all studies had control groups of the same

age distribution as the group of pyelonephritis patients.

2) Some studies were done on clinical cases, others

on autopsy cases.

3) The criteria for the diagnosis of clinical pyelo¬

nephritis are questionable, or not given.

TA

BL

E

10o

HY

PE

RT

EN

SIO

N

IN

CH

RO

NIC

PY

EL

ON

EP

HR

ITIS

-39-

* * ,P • ^ *

ftp ft O- 3 P « P Ov Ov o £ pq a o 9 3 / ON O- O 3-

OO CO 03

i—! O 3 *3 P » O- c o Ov c JS o

>$> o CO 03 VO VTV -L VO

JC ft. V. 9 O o o o o p o o -3- VO vo vrvco ■3- 03 o •H PQ -3- 03 P CO -3" vo -3 VO V3

C/3 o 0 3 & o

CO ,C & # 3 3 o o CO Ov P o o P P G o CO JN- P vo CO VftCO Ov P P

rC H P P p CO • p 0

O P >3

p » CO « p

>5 b CQ o P p p 3 P G o P

3 * O M O 3 P p P 0 3 S *H O PPG 3 0 P

CQ P 0 3 P 3 CQ P 3 ft • 3 0 0 p x a xi P £ 3 O 3 ft 3 CO p P 0 N ft 3 P 3 0 ft cd P P P 0 P CQ P 3 o 0 ® o s PH P C >3 O 3 3 3 3 p 50

P 0 3 0 0 P p o P 3 • o 3 C i—) > O P 3 p Cm G G 3 p P ft o » 0 •H (Dd 3 3 O p 0 0 O p CO W 5QrC >3 0 N • P CQ 3 >3 P P p 0 0 P Q ft ,3 CQ p 6 CD 0 3 ft * P X o CO 3 CO P 3 0 3 3 0 P CQ P CO 3 CO 0 0 0 cd 0 0 0 3 P 0 3 CQ O 3 G 3 P G 03 e P a P 45 O 50ft 50 3 P O P 0 P P 0

p 0 50ft <—1 3 0 0 G P *H P P 4_i p CO Xi 3 3 3 w •h 3 3 G o 3 3 P o

VO P P CP 3 3 Q P 3 -3- 3 Ov p 0 £ 3 3 3 0 o cd Q 0 P 3 CO 3 CO o 3 ft 0 o

CO - ft. 3 P 3 O 3 P p 0 > 0 cd ON O • O 0 O .« p ft CQ ft p ft P CQ 3 o Vft 3 O 3 p O P 3 O 3 o o O O >5 s P

3 P >3 3 3 P 3 o 3 P CQ 3 P 3 P 0 X O 0 3 ~ CQ CQ 3 w 0 ft, 3 P o O 0 £>5 ft-, >3 >> 0 3 P P p p >5 O 50 P ft > ft 3 rQ o ftp P CQ • CQ CQ CQ ftP O

!5 P 3 P 0 3 O CQ O 3 o 3 V3 G cd 0 P ° 503 o 3 3 P P P O c • 3 3-3 •H P 0 3 0 00 3 3 >> 50P 50 50 3 P 3 3 > 3 ,3 P CQ CO 3 ft. 3 p 3 3 ,P ON 50 OP 0 0 3 O 0 o O *> ft 3 P o P G P O p 3 P >3 P • • e p 3 3 Q CQ 3 P CQ •H CO P ft 50 Vi 3 P 3 3 3 ft, p ,—! CQ rP 3 CQ 3 >3,0 3 3^0 3 3 3 0 >5 0 >>ft >5 3 0 50 3 3 o CO O O EH 3 O 50 0 3 CQ P CQ P G CQ P 0 3

a •HPdP 3 POP3 0. O ft 3 ft P 3 0 >30 o & p 3 P P P 3 P O P O 3 O C G § >3 p p p^v?. P O P CQ P G p 0 P ft P P o 3 p p o o 0 x p >1 p p 3 >5 3 0 3 P CO 03 3,0 < 5 O CO CO Pn 0 O G rO P <t3 ft C P <3 o co >3 VT'*

0 3 P 0 3 3 3 0 P P >

CO W 3 O -—' 3 vo CO

■3 CO P'~' 3 P Vft 0 P CO 3 P Ov 3 co O o --- 3 v—' P 3 03 rH v—* 0 3 * * p CO 3 O CQ —• <D ft * 0 '— p 3 O CQ 3 3 *H o o 3 P 0 CQ 3 0 0 0 ft p G 0 i—! 3 50 3 O Os! P 3 CQ 3 50 ft H CQ p 3 G 3 P 3 p p 0 0 0 O 3 3 3 3 3 3 P o ft! PQ S o PQ 3 PQ 3 C/1 S 0 t-Q

TA

BL

E

10.

HY

PE

RT

EN

SIO

N

IN

CH

RO

NIC

PY

EL

ON

EP

HR

ITIS

(conti

nued)

40-

PrG • Vb V. V? 3 43 PL, O O o O Vi. O *H 0 CP CP cu 0 P £ PQ G CM O . 43 0 Vi V. 1

«H rH <M rH vp i—1 5 0 cc CO G o Sr p 43 0 up

'G p..

G o IP- O S o

On

0 «PQ

S * PQ

o V. >s V. W r 42 p; 0s- up up up 0 <r -P * V. • © a o V. CO •H PQ VO ON G CP vo 00 O 0 » 0 G- & . VO V\ 00 G G vo C\i O bO up co

•H rH Vb 0 rH

0 0 S B

CO 0 P Is co g 0 05 O 0 H o o CO

G G vp CV! CP 00 J2 “P (!) G‘ CP 3t CP PQ G

O G S rH G 0 O S £ PQ ) pi «H •H

to 0 W s CO 0 p CM 0 G

«H 0 M p 0 P G PC 3 43

0 EH P co Ei C 0

« S «H »3j P ® rd < S

Cm G co O G *H O G pi*— O c 9 43 Cm O rH H 0

05 Pi C G 0 G ■H -P 03 0 co co >* < G ■G 0 0 PQ *H 0 C S 0

G CO Pi

kr

43 03 0 43 43 G C o 05 © 0 0 43 O a 0 O bO G o PQ Pr O P G M G "H •H -P 0 43 03 H o vn, 4h G 13 P.O CO C 0 0 G CO O co 0 >5 P H £0 0 E r~l •H c Cm VO 43 G 0 EH 43 43 0 «m -P o O a 0* o M G P co co O *H G PQ rH 0 rH CO ed 0 0 0

P -P o « S rH 0 0 ffi *H G, CO 0 CO G o PQ G fe <M P ©•HP a, 43 s 0 CO ♦H £li 0 * i—1 O 0 coPG W 0 G 0 05 CO 0 rH o O bO © bO !s P-i O o c 0 G rH P S 43 «H O 43 G-

C 0 CO 0 CO G PS GPP G O G C\1 S P b£)G f» p G PS 03 3 0 H VP 0 G G O 05 0 Cm G 0 43 43 43 0 >H G 0

Cm •H S O p 0 G CO i—1 CO C CO PQ Cm bO <H 43 G Pj G S 5 0 Si 0 O *H O CO

05 op CO rH G rH O G O rH G S O o o o P 05 0 0 C 43 H S 0 S S P CO «H G PrG 0 O P O brf is co E CO £0 0 & c 43 bQ •H G *• O Pr Pr P,

■P o o 0 G P G C G G G © Pd O E O O G 43 P e 43 0 3 ®H 4-^ G 43 p PC 43 O 43 43 P 3 G ♦H J> O rH *H H *H O 0 3 P 3 3 O < a Q™ 5 o >5 o £ O S Cm <d Cm <! <5

,.,v 00 rH —

G G -P 43 G -—V r—v •H r—v £ ,— cm O- G vo E 0\ P]

0 CO Cm G G iH C cp CO H G G- o ! <—- -— C M- W 0 1 —• G ^ g G 00 G 0 G 0 0 G »—• o • P P p p «H 0 p p 0 CO (H co 0 0 •H O 0 G CO 0 0 O G 0 0 co Pd Cm G rH O 0 CO 0*2

Cm C Q 0 •H p 0 Cd s G G p 0 G U P 43 0 0 0 0 0 •H 43 0 0

Pd w PQ PQ © S Ph Ed CO EH S 0 S PL,

-41-

4) The definition of hypertension is not uniform

throughout the literature,

5) In many autopsy studies, investigators have

divided chronic pyelonephritis into various forms, e.gc,

atrophic, nonatrophic, and have only studied the incidence

of hypertension in one form or the other and thus have not

Included all cases of chronic pyelonephritis in their series.

It is apparent from this brief revieiv that the relation of

pyelonephritis to hypertension remains to be definitely

demonstrated.

In the present study 67/^ of the men and 76% of the

women with chronic pyelonephritis in the absence of obstruc¬

tion (Group I A) had a positive family history of cardio¬

vascular disease. Again one sees that the two sexes are

equally affected. The role of heredity in essential hyper¬

tension has been discussed at great length. The majority

of opinion seems to favor some sort of genetic mechanism in

hypertension, though the basis of inheritance is thought to

be multifactorial (30, 29, 4l, 4o),

In the hypertension of chronic pyelonephritis as well

as in essential hypertension, genetic factors may be im¬

portant. Kincaid-Smith et al. (19) and Sowry (40) found a

positive family history for hypertension present as fre¬

quently in a group of patients with pyelonephritis as in a

group of patients with essential hypertension, Brod (8)

-42-

found that the Incidence of hypertension in patients with

pyelonephritis over 40 years old, who had a family history

of hypertension, was 84.5^, whereas in a group of pyelonephritic

patients where there was no mention of family history the

incidence of hypertension was 59.7$» and further that the in¬

cidence of hypertension in a nonpyelonephritic control group

with a family history of hypertension was 30%a Thus it appears

that heredity and perhaps pyelonephritis both have roles in

the etiology of hypertension and that inheritance which is

believed to be a significant factor in the etiology of

essential hypertension is perhaps equally significant in the

hypertension of chronic pyelonephritis0 It has furthermore

been suggested that patients with essential hypertension are

more likely to develop chronic pyelonephritis (34, 40)o

Pertinent to this Is the study of Woods (44) which has shown

in animals that desoxycorticosterone acetate induced hyper¬

tension predisposes to renal infection,. The critical control

of this study was omitted, however, when the author neglected

to test the susceptibility of infection of rats given

desoxycorticosterone acetate before they developed hyper¬

tension 0 It can be seen that the exact interrelationship

of hypertension, heredity, and pyelonephritis are not yet

clearly defined,.

Thus this study has demonstrated that chronic pyelo¬

nephritis at autopsy in the absence of obstruction has an

^43-

equal incidence in men and women and further that there is no

histologic pattern typical of one sex or any characteristic

age distribution for either sex. Neither is there any dif¬

ference in the incidence of hypertension or positive family

history for cardiovascular disease between men and. women„

In contrast to the one to one ratio of males to

females at autopsy, the clinical incidence of urinary tract

infection heavily favors women. On reviewing the literature

(Table 11) very few studies of clinical pyelonephritis in the

absence of obstruction have been made. In Raaschou's (32)

study of 31 clinical cases of chronic pyelonephritis, there

were 14 cases in the absence of obstruction. It appears that

of the 14, 13 were female and only one was male. In a recent (11)

clinical study of urinary tract infection in the absence of

obstruction in all patients treated by the medical service

over one and a half years at the Grace New Haven Community

Hospital, the female to male ratio was ten to one. The

diagnosis of urinary tract infection in this study was based

on quantitative methods for evaluating urine bacteriology.

The discrepancy between the ten females to one male

clinically and the one female to one male at autopsy requires

an explanation. Perhaps the following can in part explain

the marked difference of the sex incidence in clinical and

pathological pyelonephritis.

-44

4 CD CD P P c- VO o 00 VC CO rH CG 4 0 vo o a VO rH tp CVI rH £ E rH VO rH -p CD rH CO Ph

0 CD e 03 i—! cm VO a CVi 4- 00 O P

0 cd CM VO CM rH H o s 00 r-l

g CD rH

4 cd E p ON CM a O CV VO P -4 £ o o- o- VO CO CVi 00 CG rH

Eh 1—1 a rH P CM

CO 0 >3 P

4m rH £ 4 £ rH Ph O 4-3 G cd rH 0 O 3t •FV O £ P O G £ 4 P £ P ON CO G £ 0 G £ 4 P O CO P •H CO £

o r*a ,P rH rH Cd P 44 8 p CO o O r-l rG 4 0 cd G 4 N P O 0 4- o p p P 05 0 Ph G G X 0 P G P 4 CG 0 p CO P -P 4 P £ 0 CO G £ £ £ On G 0 >3 G

£ P £ G O o 0 G 0 P i—! P £ G £ o a i—i b£ i PP P £ P P G 4 P G P 0 G O 4 O So 0 CO On X e P 0 G *>» P •P O X P < D £ cd 4 4 0 o G 4 £ C/1 CO G 41 0 0 ro C\2 p- P o *>. G 0 £ E 4 CD >3 , 0 £ 4 0 CO P a £ p «*■> 0 O rH O P a CO 0 O G E 0 o P G CO G CD 4-3 o o CO P CO cd 0 £ p G X E bD o

C/0 £ p £ cd P •r-1 P G cd cd £ 0 o O £ rO 4 bo i 0 G P Cd bQ G £ p p P O

CD 0 c cd CO 4 £ P G O O p a p a 0 P 0 P o •H p 0 G G 0 G CM P a o o E 1>3 P

C/1 cd 43 P o 4 4 P 4 P £ CM P CO £ >3 a 0 H o P p CO £ CO a 0 G O p CO LM Eh E G |H P 4 0 G £ £ 4 a £ P H G rO £ £ o cd G O £ £ cd P G 0 O >3 CO G « o cd G P CM £ X o p P 0 G P 4 p 0 3 P 0 0 p G (0 CO P 0 P CO P a 0 CO 4 o 03 ♦ 0 E £ p 4 4 G 'O 0 0 a cd p 4 0 E CO £ p 0 P P o ■o ♦H £ 0 P 4 4 P £ O p 0 0 p 0 a G a p 0 G CO p o G 0 • -s a X £ CO > bO G P •> P o £ 0 a 0 •H 0 p 0 O o p • C p 4 • p CO £ o G w 4-3 P P G P G bD G P cd a co p 4 bD p P Ph

P cd P 0 P P 4 4 CO G 4 0 £ E O 0 p i—1 g Pr P > P cd a cd O >5 0 0 £ C 4 P G cd

a o 4 G N 0 *H G P 4 O P £ • 4 £ G

«M 4 CO P P £ G P cd £ P P £ £ 0 o <S?J o a p bO G o 0 0 p P 0 cd CO O CO a P 4 o 0 CO O 0 G P G rO p G >1 G P P 0 0 0 H CO £ o P P 4 •H 0 G 4 X a p £ P CO >3 G 4 4 0 o £ cd © G P O 0 a 0 o G 0 0 £ £ fH •H rH bO '4 4 4 G cd P 4 a .H P 0 G £ P 41 G 0 cd p P 1—1 CO P P G G P G a 4 4 G O 0 >3 p cd cd G O p p p O 4 0 0 O £ i—1 P C X

C/1 a Q a G O 4 PQ 4 5 £ O > a a p CG 4 0 0

/—- o a

f—l p G 1—I -- 0

Q0 a o £ a 1—1 O -—- -—- a 0 o CM <—- CM <! 4 no CM CG CG P p 4 £'— —- CM

0 0 £ r-3 0 w G 0 ON £ 0 £ £ £ '— 4 O PH p O 0 O P G CO O >3 4 G co P 4 w 4 G £ G 0 4 4 — P 0 O bD Ph CO a O 0 CO £ 0 G £ o 0 0 0 0 CM 0 G 0 O o 0 a 4 4 O a 4 a a a R

aaschou

(32

) T

he

sam

e serie

s

as

ab

ov

e

- obstr

ucti

on

cases

ex

clu

ded

.

-45-

1. Urinary tract infection as seen in the clinic

bears no etiologic relationship to chronic pyelonephritis at

autopsy. This view does not seem likely because:

a) It must be kept in mind that most pyelo¬

nephritis at autopsy is found in association with obstruction,

a procedure well known to predispose the kidney to infec¬

tion. The following chart demonstrates the incidence of

pyelonephritis in association with obstruction.

Nesbit and Conger (28) 4o;£ of 1?2 cases had obstruction

Bell (2) Obstructive chronic pyelo¬ nephritis 12 times as common as nonobstructive chronic pyelonephritis

Haaschou (32) 63% of 202 cases had ob¬ struction.

Rhoads (34) 15*5% of 5^-8 cases had. obstruction.

Sanjuro (35) 98,^ of 256 cases had ob¬ struction .

The present study also demonstrates the large number

of cases of chronic pyelonephritis that are associated, with

obstruction of the genitourinary tract. It was found that

48/£ of 102 cases were associated with obstruction (see

Table 1). As obstruction is well known to predispose the

kidney to infection, it is highly probable that In a large

majority of cases, chronic pyelonephritis at autopsy is on

the basis of prior urinary tract Infection; and

b) Experimental studies have demonstrated

-46-

unequivocably that the histologic characteristics of chronic-

pyelonephritis in man can be reproduced by bacterial infec¬

tion of the kidneys in animals (24).

2. Infections in males are more easily overlooked

than infections in females. Are there a large number of men

who have clinically in apparent urinary tract infection in

which case do they have fewer or different symptoms? If this

is true, why are there fewer symptoms in men? Is this a

different kind of infection or does host response differ?

There is no definite evidence on these points but there is

no reason to support either of these possibilities. In the

present study the finding of N.P.N.'s greater than 85 mg. %

in 63^> of the men and in of the women certainly suggests

that kidney disfunction is at least as severe in men as in

women.

Since prostatitis is a common disease even in young

men one might ask whether this type of infection might be

equivalent to cystitis and posterior urethritis In women.

This could bring the clinical incidence of disease in the

sexes closer together. However no males in the present

study had a history of prostatis. (There was no information

on 4 patients.)

3. Clinical urinary tract infection in females results

in chronic pyelonephritis as seen at autopsy less frequently

than that in males. Although difficult to prove, It would

appear that many cases of urinary tract Infection in females

seem in Involve primarily the lower urinary tract and do not

result in chronic pyelonephritis. This explanation is

„4?-

reasonable and may account in part for the data obtained.

4. Although the pathologic changes called chronic

pyelonephritis may be the result of infection, they may

also result from other types of disease where the sex ratio

is closer to one to one, e.g., that associated with drugs

(phenacetin (27)), hypertension (19, 36), congenital dysplasia

(26).

5. In a further attempt to explain the discrepancy

between the ten to one ratio of females to males clinically

and the one to one ratio at autopsy, the clinical incidence

of ten to one might be questioned for as noted earlier, there

are very few clinical studies on urinary tract infection in

the absence of obstruction. Of note are Raaschou’s (32)

study on 31 patients, 14 of which were in the absence of ob¬

struction, and the recent study at the Grace New Haven Com¬

munity Hospital described previously. Both of these studies

were carried out on medical services. The incidence of

urinary tract infection in the absence of obstruction was

found to be from 10-13 females to one male in both studies.

It seems possible that some cases with this disease were

missed because they were treated on the urology service. If

this were so the clinical ratio of females to .males might be

altered. However it is not considered likely that the

number of cases that could have been missed in these studies

would be sufficient to alter the ratio of females to males

48-

from ten to one to one to one, especially since it is felt

that clinical urinary tract infection In the absence of

obstruction as seen on the urology service is much more common

in women (12). Further In support of the clinical difference

of the two sexes is the difference In incidence of a past

history of urinary tract infection in the males and females

with chronic pyelonephritis in the absence of obstruction

(see Table 4) where 0% of the men and 2>292% of the women

had a past history of urinary tract infection.

Thus 5 possibilities have been discussed in an attempt

to explain the marked difference of the ratio of males to

females with chronic pyelonephritis in the absence of obstruc¬

tion clinically and pathologically. Two of these seem reason¬

able in the light of present knowledge,

a) The frequently seen clinical urinary tract

infection In women does not invariably result in chronic

pyelonephritis as seen at autopsy,

b) The changes which we are calling pyelo¬

nephritis at autopsy are actually being produced by agents

other than infection, such as phenacetin, hypertension,

or congenital dysplasia; and that these are appearing more

frequently in the kidneys of men at autopsy, thus giving us

a false impression of the frequency of the disease we call

chronic pyelonephritis.

It is concluded that there is no thesis at the present

-49-

time which satisfactorily explains the discrepancy between

the incidence of clinical urinary tract infection and pyelo¬

nephritis at autopsy. It will remain for prospective in¬

vestigations fitted with proper controls to solve the many

unanswered questions which have been raised by the present

study.

-50-

SUMMARY AND CONCLUSIONS

Chronic pyelonephritis in the absence of obstructive

disease of the urinary tract was found in 53 instances upon

reviewing the autopsy material from January, 1957 to January,

1959 at the Grace New Haven Community Hospital, There was

an equal distribution of these cases between the sexes (^7%

were males and 53^ females). Kidneys with scars not specifically

one. called pyelonephritic demonstrated a similar one toAsex distribu¬

tion,

A review of this histologic material without prior-

knowledge of the pathologic diagnosis or the sex for both

the chronic pyelonephritic and scarred kidney groups did not

disclose any particular histologic features characteristic of

one or the other sex. Neither was there any particular age

distribution for one sex or the other. Similarly, there was

no difference between the sexes in incidence of hypertension,

family history of hypertensive vascular disease, or extent of

renal damage as measured by elevation of N.P.N. The major

difference between the sexes was the lower frequency with

which a past history of urinary tract infection was elicited

from the males as compared to the females.

The incidence of clinical urinary tract infection in

the absence of obstruction was approximately ten to one in

favor of the females. An attempt has been made to explain

-51-

the discrepancy between the sex incidence of clinical urinary-

tract infection and the sex incidence of chronic pyelonephritis

at autopsy.

-52-

APPENDIX

Footnotes for Tables 2, 3 j 6, 7> 8

a. ?0H,-TBP Past history of hypertension obtained — from the clinical records or a diastolic

pressure of 100 mm, Hg. or higher in the past.

b0 BoP. Blood Pressure, This refers to the blood pressure obtained on the patient’s last admission to the hospital, (Space blank when record of blood pressure on last admission not obtained.)

Co Fam» Hist«

'"'tBP Heart CVA

Family history of hypertension, heart disease or cerebrovascular disease. This refers to the history of one or more of these diseases In the patient’s parents or siblings.

do N.P.N. N.P.N. in mg. %„ This data was obtained by taking the highest N.P.N. on the last admission. If no N.P.N. was determined on the last admission, the highest N.P.N. of the most recent hospital admission prior to the last was recorded.

e. P.H. Past history of urinary tract infection. ~~ P-'PoPo This refers to the finding of the diagnosis

of pyelonephritis (acute or chronic), "urinary tract infection," or cystitis, in the clinical record.

f. Urine^ pos. = positive and ng = no growth or Cult. negative. Urine culture - many of these

were not evaluated o u'vi- see Method. This data was taken from the clinical record. The most recent results were recorded. In only 1 case was there a change from positive to negative and since the positive was not evaluated quantitatively, it is felt that the negative is more valid. This Is recorded as neg.

-53-

APPENDIX

(continued.)

g. Diab. Diabetes, Data obtained, from clinical record of this diagnosis at any time prior to death.

h. Kid Wt.

Kidney weight. The weight of the left kidney is expressed over the weight of the right kidney. These weights were obtained at autopsy and are in grams.

1. Micro Microscopic classification of the kidney (See Method).

NS = Nonspecific scar MFP = Minimal focal pyelonephritis TFP = Typical focal pyelonephritis DEK = Diffuse endstage kidney, pyelo¬

nephritis-like . Pye = Pyelitis No. = No abnormal tissue

*

X

This refers to a kidney weighing more than 100 grams but being described as "small" in the pathological protocol.

This refers to the presence of what¬ ever factor it IS listed under.

BIBLIOGRAPHY

1. Barker, N.W. and Walters, W„: Hypertension and chronic atrophic pyelonephritis, J.A.M.A, 115:912 , 19^0.

2. Bell, E.T.: Renal Diseases, 2nd Ed., Philadelphia, Lea and Febiger, 19p"0.

3. Birchall, R„ and Alexander, J.: Medical aspects of pyelonephritis, Medicine 29yl, 1950®

4. Boyd, W.: Changing concepts of pyelonephritis, Canadian Medical Assoc 0 -J. 47:128, 1942,

5. Braasch, W.F.: Atrophic pyelonephritis, J, Urol, ?:247, 1922.

6. Braasch, WoF0 and Jacobson, C.E0*. Chronic bilateral pyelonephritis and hypertension, JB Urol, 44:571? 19^0.

7„ Braasch, W.F., Walters, W. and Hammer, H.J.: Hyper- tension and the surgical kidney, J.A.M.A. 115:1637, 1940.

8. Brod, J.; Chronic pyelonephritis, Lancet 270:973, 19560

9. Caulk, J.R.: Pyelonephritis, its incidence, engendering elements and impelling Influences, J.Urol. 16:117, 1926.

10. Fishberg, A.E.: Hypertension and Nephritis, 5th ed., Philadelphia, Lea”and™Febiger, 19J0.

11o Freedman, L.R.: Observations on patients with acute urinary tract infection, Presented at the International Symposium: The Biology of Pyelonephritis, Henry Ford Hospital, October, 1959®

12. Glenn, J.F.: Personal communication.'

13® Goldring, W. and Chasis, H.: Hypertension and Hyper¬ tensive Disease, New York Commonwealth Fund", T9447

14. Jackson, G.G., Dallenbach, F.D0, Kipnls, G.P.: Pyelo- nephritis, correlation of clinical and pathologic observations in the antibiotic era, M. Clin. N. Am.

39:297, 1955®

15® Jackson, G.G., Poirier, K.P., and Grieble, H.C.: Con¬ cepts of pyelonephritis: experience with renal biopsies and long term clinical observations, Ann. Int. Med. 47:1165, 1957®

-55-

16o Jawetz, E.s Urinary Tract Infections, Disease-a-Month, November, 1954.

17, Keefer, C.S.: Pyelonephritis - its natural history and course, Bull, Johns Hopkins Hospc 100:107, 1957.

18, Kincaid-Smith, P.s Vascular obstruction in chronic pyelonephritic kidneys and its relationship to hyper¬ tension, Lancet 269:1263 , 1955*

19, Kincaid-Smith, P. , McMichael, J., and Murphy, E.A.: The clinical course and pathology of hypertension with oapilloedema (malignant hypertension), Quart, J. Med, 275117, 1958,

20, Kinney, T'.D. and Mallory, G.K.: Personal communication cited by Mansfield, J.S., Mallory, G.X., and Ellis, L.B, The differential diagnosis of chronic Bright’s Disease: A clinicooathological correlation, New England J. Med.

29:387, 1943.

21. Likely, D.S., Lisa, J.R., and Solomon, C.: Pyelo¬ nephritis with death in uremia, J.A.M.A. 119:397, 1942.

22. Longcope, W.T.: Chronic bilateral pyelonephritis -- its origin and its association with hypertension, Ann. Int, Med. 11:149,1937.

23. Loopuyt, L.: Infections of the urinary tract, II. Therapeutic results, Acta Med. Scandinav. 125:357, 1946.

24. Mallory, G.K., Crane, A.S., and Edwards, J.E.: Pathology of acute and of healed experimental pyelo¬ nephritis, Arch. Path. 30:330,1940.

25. Mansfield, J.S., Mallory, G.K., and Ellis, L.B.: The differential diagnosis of chronic Bright's Disease: A clinicopathological correlation, New England. J. Med. 229:387, 1943.

26. Marshall, A.G.: Scars of the renal cortex, J. Path. Bact. 71: 1956o

27. Moclten, S.E., and Smith, I.B.: Fatal nephritis in chronic phenacetin poisoning, Am. J. Med. 215:127, i960.

28. Nesbit, R.M., and Conger, K.B.: Chronic pyelonephritis, .New York State J. Med. 42:225, 1942.

29. Pickering, G.W.: Genetic factors In essential hyper¬ tension, Ann. Int. Med. 43:457, 1955.

-56-

30. Platt, R.: Heredity in hypertension, Quart. -J. Med. 16:111, 1947.

31. Putschar, W.: Some aspects of the pathology of pyelonephritis, J. Urol. 43_:793? 1940.

32. Raaschou, F„: Studies of Chronic Pyelonephritis, Copenhagen, Ejnar Munksgaard, 1948.

33. Rantz, L.A.; Infections of the urinary tract, Adv.nb-K Med. 1:137, 1942.

34. Rhoads, P.S.: The incidence and clinical importance of pyelonephritis in patients with hypertension, Hypertension2 The first Hahnemann symposium on hypertensive disease. Philadelphia, W.B. Saunders, 1959*

35® Sanjuro, L.A. and Fortuno, R.F.: Clinical and pathological study of pyelonephritis in Puerto Rico. Review of 2,800 autopsies, 1,887 clinical records, J. Urol. 77 039? 1957®

36. Saphir, 0. and Taylor, B0: Pyelonephritis lenta, Ann. Int. Med. 36:1017, 1952.

37® Schreiner, G.E.: The clinical and histologic spectrum of pyelonephritis, A.M.A. Arch. Int. Med. 102:32, 1958.

38. Schroeder, H.A. and Steele, J.M.: Studies on "essentlaln hypertension II. The association of hypertension with organic renal disease, Arch. Int, Med. 68_:26l, 1941.

39. Shure, N.M0: Pyelonephritis and hypertension, A study of their relation in 11,898 necropsies. Arch. Int. Med. 70:284, 1942.

4o„ Sowry, G.S.C.: Hypertension the coincidence of conditions, Part I. Post graduate Medical Journal (London) 34:39-48, 82-88, 1958.

41. Thomas, C.B.: The heritage of hypertension, Tr. A. Am. Physicians 65.: 121, 1952.

42. Weiss, S. and Parker, F., Jr.: Pyelonephritis -- its relation to vascular lesions and to arterial hyperten¬ sion, Medicine 1.8:222, 1939®

43. Weiss, S. and Parker, F.5 Jr.: Relation of pyelonephritis and otter urinary tract Infections to arterial hyper¬ tension, New England J. Med. 223:959» 1940.

44. Woods, J.W.; Susceptibility of rats with hormonal hyper¬ tension to experimental pyelonephritis, J. Clin. Investiga¬ tion, 37:1686, 1958.

\

YALE MEDICAL LIBRARY

Manuscript Theses

Unpublished theses submitted for the Master's and Doctor's degrees and

deposited in the Yale Medical Library are to be used only with due regard to the

rights of the authors. Bibliographical references may be noted, but passages

must not be copied without permission of the authors, and without proper credit

being given in subsequent written or published work.

This thesis by has been

used by the following persons, whose signatures attest their acceptance of the

above restrictions.

NAME AND ADDRESS DATE