Pyelonephritis

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Chronic pyelonephritis
)
Pyelonephritis
Other namesKidney infection
kidney stones[2]
PreventionUrination after sex, drinking sufficient fluids[1]
MedicationAntibiotics (ciprofloxacin, ceftriaxone)[4]
FrequencyCommon[5]

Pyelonephritis is inflammation of the

bacterial infection.[3] Symptoms most often include fever and flank tenderness.[2] Other symptoms may include nausea, burning with urination, and frequent urination.[2] Complications may include pus around the kidney, sepsis, or kidney failure.[3]

It is typically due to a bacterial infection, most commonly

urinary tract, and spermicide use.[2][3] The mechanism of infection is usually spread up the urinary tract.[2] Less often infection occurs through the bloodstream.[1] Diagnosis is typically based on symptoms and supported by urinalysis.[2] If there is no improvement with treatment, medical imaging may be recommended.[2]

Pyelonephritis may be preventable by urination after sex and drinking sufficient fluids.

kidney stones, surgery may be required.[1][3]

Pyelonephritis affects about 1 to 2 per 1,000 women each year and just under 0.5 per 1,000 males.[5][7] Young adult females are most often affected, followed by the very young and old.[2] With treatment, outcomes are generally good in young adults.[3][5] Among people over the age of 65 the risk of death is about 40%, though this depends on the health of the elderly person, the precise organism involved, and how quickly they can get care through a provider or in hospital.[5]

Signs and symptoms

Diagram showing the typical location of pain[8]

Signs and symptoms of acute pyelonephritis generally develop rapidly over a few hours or a day. It can cause high fever, pain on passing urine, and abdominal pain that radiates along the flank towards the back. There is often associated vomiting.[9]

Chronic pyelonephritis causes persistent flank or abdominal pain, signs of infection (fever, unintentional weight loss, malaise, decreased appetite), lower urinary tract symptoms and blood in the urine.[10] Chronic pyelonephritis can in addition cause fever of unknown origin. Furthermore, inflammation-related proteins can accumulate in organs and cause the condition AA amyloidosis.[11]

Physical examination may reveal fever and tenderness at the costovertebral angle on the affected side.[12]

Causes

Most cases of community-acquired pyelonephritis are due to bowel organisms that enter the urinary tract. Common organisms are

cystitis and prostatitis.[9] E. coli can invade the superficial umbrella cells of the bladder to form intracellular bacterial communities (IBCs), which can mature into biofilms. These biofilm-producing E. coli are resistant to antibiotic therapy and immune system responses, and present a possible explanation for recurrent urinary tract infections, including pyelonephritis.[13] Risk is increased in the following situations:[9][14]

Diagnosis

Laboratory examination

antibiotic sensitivity testing are useful for establishing a formal diagnosis,[9] and are considered mandatory.[15]

Imaging studies

If a kidney stone is suspected (e.g. on the basis of characteristic

voiding cystourethrography.[9] CT scan or kidney ultrasonography is useful in the diagnosis of xanthogranulomatous pyelonephritis; serial imaging may be useful for differentiating this condition from kidney cancer.[10]

Acute pyelonephritis with increased cortical echogenicity and blurred delineation of the upper pole.[20]

Ultrasound findings that indicate pyelonephritis are enlargement of the kidney, edema in the renal sinus or parenchyma, bleeding, loss of corticomedullary differentiation, abscess formation, or an areas of poor blood flow on

doppler ultrasound.[21] However, ultrasound findings are seen in only 20% to 24% of people with pyelonephritis.[21]

A DMSA scan is a radionuclide scan that uses dimercaptosuccinic acid in assessing the kidney morphology. It is now[when?] the most reliable test for the diagnosis of acute pyelonephritis.[22]

Classification

Acute pyelonephritis

Acute pyelonephritis is an exudative purulent localized inflammation of the renal pelvis (collecting system) and kidney. The kidney parenchyma presents in the interstitium abscesses (suppurative necrosis), consisting in purulent exudate (pus): neutrophils, fibrin, cell debris and central germ colonies (hematoxylinophils). Tubules are damaged by exudate and may contain neutrophil casts. In the early stages, the glomerulus and vessels are normal. Gross pathology often reveals pathognomonic radiations of bleeding and suppuration through the renal pelvis to the renal cortex.[citation needed]

Chronic pyelonephritis

Chronic pyelonephritis implies recurrent kidney infections and can result in scarring of the renal parenchyma and impaired function, especially in the setting of obstruction. A perinephric abscess (infection around the kidney) and/or pyonephrosis may develop in severe cases of pyelonephritis.[23]

  • Abscess around both kidneys[24]
  • Abscess around both kidneys[24]
  • Chronic pyelonephritis with reduced kidney size and focal cortical thinning. Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line.[20]
    Chronic pyelonephritis with reduced kidney size and focal cortical thinning. Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line.[20]
Xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis is an unusual form of chronic pyelonephritis characterized by granulomatous abscess formation, severe kidney destruction, and a clinical picture that may resemble renal cell carcinoma and other inflammatory kidney parenchymal diseases. Most affected individuals present with recurrent fevers and urosepsis, anemia, and a painful kidney mass. Other common manifestations include kidney stones and loss of function of the affected kidney. Bacterial cultures of kidney tissue are almost always positive.[25] Microscopically, there are granulomas and lipid-laden macrophages (hence the term xantho-, which means yellow in ancient Greek). It is found in roughly 20% of specimens from surgically managed cases of pyelonephritis.[10]

Prevention

In people who experience recurrent urinary tract infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to reduce the likelihood of recurrence. If no abnormality is identified, some studies suggest long-term

preventive treatment with antibiotics, either daily or after sexual activity.[26] In children at risk for recurrent urinary tract infections, not enough studies have been performed to conclude prescription of long-term antibiotics has a net positive benefit.[27] Cranberry products and drinking cranberry juice appears to provide a benefit in decreasing urinary tract infections for certain groups of individuals.[28]

Management

In people suspected of having pyelonephritis, a urine culture and

antibiotic sensitivity test is performed, so therapy can eventually be tailored on the basis of the infecting organism.[5] As most cases of pyelonephritis are due to bacterial infections, antibiotics are the mainstay of treatment.[5] The choice of antibiotic depends on the species and antibiotic sensitivity profile of the infecting organism, and may include fluoroquinolones, cephalosporins, aminoglycosides, or trimethoprim/sulfamethoxazole, either alone or in combination.[15]

Simple

A 2018 systematic review recommended the use of norfloxacin as it has the lowest rate of side effects with a comparable efficacy to commonly used antibiotics.[29]

In people who do not require hospitalization and live in an area where there is a low prevalence of

beta-lactam antibiotics are less effective than other available agents for treatment of pyelonephritis.[15] Improvement is expected in 48 to 72 hours.[5]

Complicated

People with acute pyelonephritis that is accompanied by high fever and leukocytosis are typically admitted to the hospital for intravenous hydration and intravenous antibiotic treatment. Treatment is typically initiated with an intravenous fluoroquinolone, an aminoglycoside, an extended-spectrum penicillin or cephalosporin, or a carbapenem. Combination antibiotic therapy is often used in such situations. The treatment regimen is selected based on local resistance data and the susceptibility profile of the specific infecting organism(s).[15]

During the course of antibiotic treatment, serial white blood cell count and temperature are closely monitored. Typically, the intravenous antibiotics are continued until the person has no fever for at least 24 to 48 hours, then equivalent antibiotics by mouth can be given for a total of two–week duration of treatment.

amoxicillin/clavulanic acid) or with short courses (2 to 4 days) of intravenous therapy followed by oral therapy.[31] If intravenous therapy is chosen, single daily dosing with aminoglycosides is safe and effective.[31]

Fosfomycin can be used as an efficacious treatment for both UTIs and complicated UTIs including acute pyelonephritis. The standard regimen for complicated UTIs is an oral 3g dose administered once every 48 or 72 hours for a total of 3 doses or a 6 grams every 8 hours for 7 days to 14 days when fosfomycin is given in IV form.[32]

Treatment of xanthogranulomatous pyelonephritis involves antibiotics as well as surgery. Removal of the kidney is the best surgical treatment in the overwhelming majority of cases, although polar resection (partial nephrectomy) has been effective for some people with localized disease.[10][33] Watchful waiting with serial imaging may be appropriate in rare circumstances.[34]

Follow-up

If no improvement is made in one to two days post therapy, inpatients should repeat a urine analysis and imaging. Outpatients should check again with their doctor.[35]

Epidemiology

There are roughly 12–13 cases annually per 10,000 population in women receiving outpatient treatment and 3–4 cases requiring admission. In men, 2–3 cases per 10,000 are treated as outpatients and 1–2 cases/10,000 require admission.[36] Young women are most often affected. Infants and the elderly are also at increased risk, reflecting anatomical changes and hormonal status.[36] Xanthogranulomatous pyelonephritis is most common in middle-aged women.[25] It can present somewhat differently in children, in whom it may be mistaken for Wilms' tumor.[37]

Research

According to a 2015 meta analysis, vitamin A has been shown to alleviate renal damage and/or prevent renal scarring.[38]

Terminology

The term is from

-itis suggesting "inflammation".[citation needed
]

A similar term is "pyelitis", which means inflammation of the renal pelvis and calyces.[39][40] In other words, pyelitis together with nephritis is collectively known as pyelonephritis.[citation needed]

Etymology

The word pyelonephritis is formed by the

diseases or inflammations.[citation needed
]

See also

References

  1. ^ a b c d e "Kidney Infection (Pyelonephritis)". NIDDK. April 2017. Archived from the original on 4 October 2017. Retrieved 30 October 2017.
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  8. ^ "Urinary Tract Infection Common Clinical and Laboratory Features of Acute Pyelonephritis". netterimages.com. Retrieved 14 July 2019.
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  16. ^ Pearle MS, Calhoun EA, Curhan GC (2007). "Chapter 8: Urolithiasis" (PDF). In Litwin MS, Saigal CS (eds.). Urologic Diseases in America (NIH Publication No. 07–5512). Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. pp. 283–319. Archived (PDF) from the original on 2011-09-15.
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  23. ^ Griebling TL (2007). "Chapter 18: Urinary Tract Infection in Women" (PDF). In Litwin MS, Saigal CS (eds.). Urologic Diseases in America (NIH Publication No. 07–5512). Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. pp. 589–619. Archived (PDF) from the original on 2011-09-27.
  24. ^ a b "UOTW #72 - Ultrasound of the Week". Ultrasound of the Week. 11 July 2016. Archived from the original on 16 November 2016. Retrieved 27 May 2017.
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  39. ^ medilexicon.com Archived 2014-01-06 at the Wayback Machine
  40. ^ Using Medical Terminology: A Practical Approach 2006 p.723

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