Ureteric reflux 1973: chronic pyelonephritis v. reflux nephropathy.

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This is the first annotation in an occasional column that will examine matters of current interest. Readers' comments are invited on this as on any other feature of the journal.—The Editors. A lingering inflammation of the renal pelvis and parenchyma? Richard Asher might well have chosen chronic pyelonephritis as an example of the corrupting power of the sloppy word in medicine (Asher, 1972). Naming a condition amounts to much more than mere labelling: it imprints indelible ideas about aetiology. We have all found it rather hard to accept in recent years that the coarsely scarred kidney is generally the end stage of a childhood event, not the lingering, smouldering counterpart of chronic infections acquired in adult life. Worse is to come: bacterial infection of the kidney may not be the starting point of the disorder at all. Chronic pyelonephritis appeared an established clinical and pathological entity by the 1950s, with protagonists divided between haematogenous and ascending infection routes. At this time experimental studies in the rabbit and mouse showed that bacteraemic insults alone would produce the characteristic coarsely scarred kidney (De Navasquez, 1958). It is of interest that “intra-renal hydronephrosis”, abnormal dilatation of renal tubules, was a well-known complication in these studies, leading to speculation on the intra-renal urodynamic upset that might follow such changes. But a decade later vesico-ureteric reflux had come to be recognized as an important association of the coarsely scarred kidney in man (The Lancet, 1968), and is still pressing to the centre of the stage. Bacteraemia, or indeed bacteria anywhere have had an increasingly hard time in the wings.