Tumorous nodules in the native kidney in a woman transplanted 3 years earlier because of “chronic pyelonephritis”-induced renal failure B. Ivanyi Department of Pathology University of Medicine, Szeged, Hungary

Data retrieved from our files May 2007: a 54-year-old woman with chronic renal failure due to “bilateral chronic pyelonephritis” received an allograft from a deceased donor Sept 2007 (protocol Bx): no alteration May 2008 (protocol Bx): Tac toxicity and acute TMR July 2010 (Bx for cause): C4d/+/ chronic AMR Oct 2010: removal of the right native kidney because of tumour at the pyeloureteral border

Tumorous nodules in the pelvis, calyces Dilated pelvis and calyces Markedly atrophied medulla and cortex Tips of the papillae were pale Gross changes

Papillary tumour in the calyx; fibrotic papilla, atrophied medulla and cortex

The tumour proved invasive urothelial cell carcinoma

Focally, UCC displayed high grade features

The papillae were fibrotic, showed areas of calcification, and were sharply demarcated from the medulla

Hyalinized, structureless papilla; chronic TIN in the medulla

Cortex: obsoleted glomeruli, disappeared/atrophied tubuli

“What would be your diagnosis?”

Our diagnosis Phenacetin kidney-induced end-stage kidney and multifocal urothelial carcinoma of the pelvis and calyces

The nephrology departments were consulted for a review of the patient’s medical history. The woman had consumed phenacetin-containing analgesic agents for 15 years ( ) because of headaches and pains due to osteoarthosis : chronic renal insufficiency attributed to phenacetin abuse had ensued; while on the waiting list, the diagnosis of phenacetin kidney had been amended to chronic pyelonephritis. 2007: kidney Tx. The surgeons who regularly controlled the allograft function had not been aware that the woman’s native kidney disease was phenacetin kidney.

: painless microhaematuria; the native kidneys had not been scanned by ultrasonography Sept 2010: admitted to the county hospital with uremic symptoms. Abdominal ultrasonography: a tumour in the right native kidney, which caused hydronephrosis Oct 2010: removal of the tumorous kidney April 2011: death because of disseminated cancer

Comment The association between phenacetin-containing analgesics and the development of urinary tract carcinoma was first reported from Sweden in Subsequent studies confirmed that patients with phenacetin kidney were at an increased risk of the development of UCC; the induction time was calculated between 20 and 25 years. Despite regular tumour screening via urine cytology and abdominal sonography in patients with phenacetin kidney after renal transplantation, the diagnosis of urothelial carcinoma was still made late in many patients.

Comment The prohibition of phenacetin-containing analgetics led to a significant decrease in the incidence of phenacetin kidney in Hungary, and a potential long-term consequence of analgesic consumption, the development of urothelial carcinoma of the urinary tract, has subsequently become exceptional.

The hyalinized, structureless papillae with calcifications led us to the histopathological diagnosis of end-stage kidney due to phenacetin kidney. Our diagnosis was confirmed by the patient’s medical history. The multifocal urothelial carcinoma was obviously induced by the analgesic abuse. The presented case is an example of how the pathologist can sometimes put things order.