Tuberculosis of the Kidney
Authors: J. Thomson-Walker
Journal: BMJ (1927)

TUBERCULOSIs of the kidney illustrates the advance in diagnosis and treatment in renal surgery in the last twenty- five years.The mortality of nephrectomy for tuberculosis of the kidney between 1890 and 1900 was 25.4 per cent.'At that time no adequate means of ascertaining the presence and condition of the second kidney were generally emploved.Tihe use of the ureteral catlheter and the tests of the renal function, together with a more accutrate ,knowledge of the pathology of renal tuberculosis, have reduced the operation mortality to 2 or 3 per cent. SURGICAL PATHOLOGY.Renal tuberculosis is a disease of young adult life, and occurs most frequently between the ages of 20 and 40.It is rare in children, and in them is more frequently bilateral in the early stages.The disease is uncommon over 50 years, and at this age is more chronic than in middle life.The male sex is more frequentlv affected thani the Jfernale in a ratio of about 2 to 1.In adults chronic renal ,tuberculosis is unilateral in from 80 to 90 per cent. of cases in the early stage.Source anld Route of the Infection.In the strict meaning pr-imarv tuberculosis of the kidney 'canniot be said to exist.A pr-imary focus is always present elsewhere in the bo(ly, althlouglh it may not be discovered clinically.Braasch2 places the coincident lesions discovpred in 346 operated cases at 71 per cent.Others have found a lower proportion of coincidenit lesions in clinical work.,Thus Persson3 states the figure at 50 per cent., and in 193 cases operated on by myself 48.1 per cenit.lhad evideitce of obsolete tubercle elsewhere in the body.A history of pleuurisy anid clinical evidence of obsolete pulmoniary tuberculosis is common, while post-mttor tent evidence shows that tuberculous glands of the miiediastinum' are present in a large proportion of cases.Active pulmonary tuberculosis is found coincident with renal tuber- culosis in a small number of cases (5.3 per cent.).Tuberculous lesions-which must, equally with renal tuber- culosis, be secondary are found in other parts of the body.The exact relationship of these to the renal lesion is not always clear, but some of themii miiay be the immediate source of the tubercle bacilli that infect the kidney.In order of frequency these are genital tuberculosis in the male and tuberculosis of bones and joints.In my cases submitted to operatlon there were tuberculous lesions of the epididymis in 23.3 per cent., of the prostate in 15.3 per cent., and of the seminal vesicles in 7.3 per eent.There are three possible paths-namely, the ascending or urinary by the lumen of the ureter, the lymphatic, and the haematogenous.There is -experimental evidence that, under certain con- ditions, ascending infection by the lumen of the ureter may occur (Wildbolz4); there is histological evidence that lymphatic infection along the ureter may take plaoe (Bauereisen,5 Walker6); and there is pathological evidence that supports lymphatic infection from the thorax (Brongersma7).The weight of evidence at the present time supports the view that in renal tuberculosis the tuberele bacillus is blood-borne.VARIETIES OF RENAL TUBERCULOSIS.It is possible to reduce the many varieties of renal tuberculosis that have been described to three: (1) miliary tuberculosis, (2) chronic renal tuberculosis, and (3) tuber- culous nephritis. Miliary Tuberculosis.Thlis is an acute condition in which both kidneys are strewn with tubercles.It is part of a general tuber- culosis, and is of no surgical interest.Chronic Renal Tuberculosis.IUnder this head are included almost all forms of renal tuberculosis that come under the care of the surgeon.It includes the conditions known as apical tuberculosis, uleero- cavernous tuberculosis, tuberculous hydronephrosis, caseous tuberculosis, nodular tuberculosis, and tuberculous abscess.The first change, in the great majority of cases, takes place at the apex of a pyramid.There is a small loss of substance surrounded by a zone of inflammation.