Renal disease in tuberculosis
- Vernon M Pais, Jr, MD
Vernon M Pais, Jr, MD
- Associate Professor of Surgery/Urology
- Geisel School of Medicine at Dartmouth
- Jodie Dionne-Odom, MD
Jodie Dionne-Odom, MD
- Assistant Professor of Medicine
- Division of Infectious Diseases
- University of Alabama at Birmingham
- Section Editors
- C Fordham von Reyn, MD
C Fordham von Reyn, MD
- Section Editor — Tuberculosis; Nontuberculous Mycobacterial Infections
- Professor of Medicine
- Geisel School of Medicine at Dartmouth
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
Tuberculosis may lead to renal dysfunction via a range of mechanisms; these include direct infection of the kidney and lower urinary tract, tubulointerstitial nephritis, glomerulonephritis, secondary amyloidosis, and obstructive uropathy. Associated adverse effects include mild hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) induced by pulmonary involvement and nephrotoxicity induced by antimycobacterial agents.
TUBERCULOUS URINARY TRACT INFECTION
Genitourinary tuberculosis (TB) is a common form of extrapulmonary disease; an estimated 4 to 20 percent of individuals with pulmonary infection develop genitourinary involvement, mostly in developing countries [1,2]. Genitourinary TB is more common in men than in women. Hematogenous seeding at the time of primary pulmonary infection can lead to renal involvement; infection can also occur in the setting of late reactivation disease or miliary disease. Of patients with miliary disease, 25 to 62 percent have been documented to have concomitant renal lesions . (See "Clinical manifestations, diagnosis, and treatment of miliary tuberculosis" and "Epidemiology and pathology of miliary and extrapulmonary tuberculosis".)
Mycobacterial seeding leads to granuloma formation in proximity to glomeruli. These may heal with fibrosis in the absence of overt renal disease. Alternatively, the granulomas may caseate and rupture into the tubular lumen; this can occur up to 30 years after the initial infection. Subsequently, tuberculous bacilli can enter the medullary interstitium, leading to granuloma formation and progressive medullary injury [4,5]. Destruction of renal papilla can lead to calyceal ulceration or abscess formation. Involvement of the collecting system may result in fibrotic scarring and stenosis.
Clinical manifestations — The onset of genitourinary TB is usually insidious, presenting with malaise and lower urinary tract symptoms, including dysuria and gross hematuria [4-6]. Renal colic is an uncommon manifestation. Systemic symptoms (fever, weight loss) are relatively rare, since rupture of the glomerular granulomas occurs independently of disease activity at other sites [4,7]. Some patients are asymptomatic; in such cases, pyuria and/or microscopic hematuria may be observed as incidental findings.
Pyuria and/or microscopic hematuria are present in more than 90 percent of cases . Heavy proteinuria and cellular casts are not generally seen, and the plasma creatinine concentration is usually normal. Ureteral stricture can occur and may cause obstructive uropathy [7,8]. TB can also cause chronic epididymitis or prostatitis and should be considered in cases that fail to respond to antibacterial therapy. Infertility can occur in the setting of tuberculous involvement of seminal vesicles and ejaculatory ducts in men and fallopian tubes in women . Late presentation of genitourinary TB with end-stage renal disease can be irreversible .
- Abbara A, Davidson RN, Medscape. Etiology and management of genitourinary tuberculosis. Nat Rev Urol 2011; 8:678.
- Bhatt C, Lodha S. Paraspinal sinuses? Do remember renal tuberculosis. BMJ Case Rep 2012; 2012.
- Figueiredo AA, Lucon AM. Urogenital tuberculosis: update and review of 8961 cases from the world literature. Rev Urol 2008; 10:207.
- Simon HB, Weinstein AJ, Pasternak MS, et al. Genitourinary tuberculosis. Clinical features in a general hospital population. Am J Med 1977; 63:410.
- Christensen WI. Genitourinary tuberculosis: review of 102 cases. Medicine (Baltimore) 1974; 53:377.
- Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med 2000; 161:1376.
- Eastwood JB, Corbishley CM, Grange JM. Tuberculosis and the kidney. J Am Soc Nephrol 2001; 12:1307.
- Li SY, Wang KL, Chen JY, Chen TW. Tuberculous autonephrectomy. Kidney Int 2006; 69:1924.
- Lima NA, Vasconcelos CC, Filgueira PH, et al. Review of genitourinary tuberculosis with focus on end-stage renal disease. Rev Inst Med Trop Sao Paulo 2012; 54:57.
- Marks LS, Poutasse EF. Hypertension from renal tuberculosis: operative cure predicted by renal vein renin. J Urol 1973; 109:149.
- Raghavaiah NV. Tuberculosis of the male urethra. J Urol 1979; 122:417.
- Raut VS, Mahashur AA, Sheth SS. The Mantoux test in the diagnosis of genital tuberculosis in women. Int J Gynaecol Obstet 2001; 72:165.
- Feng Y, Diao N, Shao L, et al. Interferon-gamma release assay performance in pulmonary and extrapulmonary tuberculosis. PLoS One 2012; 7:e32652.
- Lattimer JK, Reilly RJ, Segawa A. The significance of the isolated positive urine culture in genitourinary tuberculosis. J Urol 1969; 102:610.
- Amin I, Idrees M, Awan Z, et al. PCR could be a method of choice for identification of both pulmonary and extra-pulmonary tuberculosis. BMC Res Notes 2011; 4:332.
- Chawla A, Chawla K, Reddy S, et al. Can tissue PCR augment the diagnostic accuracy in genitourinary tract tuberculosis? Urol Int 2012; 88:34.
- Hillemann D, Rüsch-Gerdes S, Boehme C, Richter E. Rapid molecular detection of extrapulmonary tuberculosis by the automated GeneXpert MTB/RIF system. J Clin Microbiol 2011; 49:1202.
- Becker JA. Renal tuberculosis. Urol Radiol 1988; 10:25.
- Kollins SA, Hartman GW, Carr DT, et al. Roentgenographic findings in urinary tract tuberculosis. A 10 year review. Am J Roentgenol Radium Ther Nucl Med 1974; 121:487.
- Huang LH, Wen MC, Hung SW, et al. Renal tuberculosis presenting as a complicated renal cyst. Urology 2012; 80:e69.
- Gaudiano C, Tadolini M, Busato F, et al. Multidetector CT urography in urogenital tuberculosis: use of reformatted images for the assessment of the radiological findings. A pictorial essay. Abdom Radiol (NY) 2017.
- Teo EY, Wee TC. Images in clinical medicine: Renal tuberculosis. N Engl J Med 2011; 365:e26.
- Javaud N, Belenfant X, Stirnemann J, et al. Renal granulomatoses: a retrospective study of 40 cases and review of the literature. Medicine (Baltimore) 2007; 86:170.
- Chapagain A, Dobbie H, Sheaff M, Yaqoob MM. Presentation, diagnosis, and treatment outcome of tuberculous-mediated tubulointerstitial nephritis. Kidney Int 2011; 79:671.
- Latus J, Amann K, Braun N, et al. Tubulointerstitial nephritis in active tuberculosis - a single center experience. Clin Nephrol 2012; 78:297.
- Eastwood JB, Corbishley CM, Grange JM. Tuberculosis and tubulointerstitial nephritis: an intriguing puzzle. Kidney Int 2011; 79:579.
- Sun L, Yuan Q, Feng J, et al. Be alert to tuberculosis-mediated glomerulonephritis: a retrospective study. Eur J Clin Microbiol Infect Dis 2012; 31:775.
- Kennedy AC, Burton JA, Allison ME. Tuberculosis as a continuing cause of renal amyloidosis. Br Med J 1974; 3:795.
- le Roux DM, Pillay K, Nourse P, et al. Systemic amyloidosis complicating multidrug-resistant tuberculosis in childhood. Pediatr Infect Dis J 2012; 31:994.
- Falck HM, Törnroth T, Wegelius O. Predominantly vascular amyloid deposition in the kidney in patients with minimal or no proteinuria. Clin Nephrol 1983; 19:137.
- Hill AR, Uribarri J, Mann J, Berl T. Altered water metabolism in tuberculosis: role of vasopressin. Am J Med 1990; 88:357.
- Berns JS, Cohen RM, Stumacher RJ, Rudnick MR. Renal aspects of therapy for human immunodeficiency virus and associated opportunistic infections. J Am Soc Nephrol 1991; 1:1061.
- Soffer O, Nassar VH, Campbell WG Jr, Bourke E. Light chain cast nephropathy and acute renal failure associated with rifampin therapy. Renal disease akin to myeloma kidney. Am J Med 1987; 82:1052.
- Guggino SE, Martin GJ, Aronson PS. Specificity and modes of the anion exchanger in dog renal microvillus membranes. Am J Physiol 1983; 244:F612.
- Gow JG, Barbosa S. Genitourinary tuberculosis. A study of 1117 cases over a period of 34 years. Br J Urol 1984; 56:449.
- Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med 1985; 79:467.
- Gokce G, Kilicarslan H, Ayan S, et al. Genitourinary tuberculosis: a review of 174 cases. Scand J Infect Dis 2002; 34:338.
- Gow JG. Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease. Br J Urol 1970; 42:647.
- Psihramis KE, Donahoe PK. Primary genitourinary tuberculosis: rapid progression and tissue destruction during treatment. J Urol 1986; 135:1033.
- Shin KY, Park HJ, Lee JJ, et al. Role of early endourologic management of tuberculous ureteral strictures. J Endourol 2002; 16:755.
- Cek M, Lenk S, Naber KG, et al. EAU guidelines for the management of genitourinary tuberculosis. Eur Urol 2005; 48:353.
- TUBERCULOUS URINARY TRACT INFECTION
- Clinical manifestations
- - Urine studies
- - Radiography
- ASSOCIATED CONDITIONS
- Tuberculous interstitial nephritis
- Tuberculous glomerulonephritis
- Secondary amyloidosis
- Drug-induced nephrotoxicity
- M. bovis infection due to intravesical BCG
- SOCIETY GUIDELINE LINKS