Question 1 of 10

    Acute Pyelonephritis

    Acute pyelonephritis is a condition incited by a bacterial infection that affects the parenchymal tissue of the kidneys. It is, most frequently, a complication of a lower urinary tract infection that has allowed pathogens to further infiltrate the kidneys; alternatively, bacteria can access the kidney through the bloodstream. Acute pyelonephritis can eventuate in septic phenomena, abscess of the kidney or a chronic state of inflammation and secondarily, kidney failure

    Acute Pyelonephritis results from the following process: infectious.

    Presentation

    An episode of acute pyelonephritis typically presents with three symptoms: fever, nausea and costovertebral angle pain. Although this is termed as the classic symptomatology of pyelonephritis, these three symptoms may not be simultaneously present or some may not be manifested at all. Fluctuation in the severity of the symptoms is naturally expected, and may even develop gradually, instead of acutely. Even though acute pyelonephritis usually develops as a result of a prior, complicated lower UTI infection, the latter's symptoms may not be present at the time of diagnosis.

    A lower UTI infection exhibits a characteristic symptomatology, including hematuria, fever, dysuria and frequent, urgent urination. Approximately 1/3 of female patients with pyelonephritis exhibit the symptom of hematuria; should the patient be male, an investigation of other causes of hematuria should promptly be investigated. Febrile patients commonly exhibit chills or rigor as well, alongside fatigue and weakness. Temperature is not expected to exceed an average of 103°F (39.4°C).

    The pain felt at the costovertebral angle is characteristically triggered by percussion and it is usually experienced at the side of the affected kidney. Gastrointestinal symptoms, such as vomiting or anorexia may also be present.

    Children may lack the typical symptoms of acute pyelonephritis, a fact which renders the diagnosis considerably more difficult. Particularly infants or neonates who cannot yet express themselves verbally may evince anorexia, lethargy, fever and vomiting. Senior patients may experience symptoms that are identical to those of a lower UTI infection, or clinical manifestations that include a mental status impairment, fever and organ failure.

    Entire body system
    Chills
    • You have a fever and chills.[drugs.com]
    • […] bacteria § E. coli § Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously · Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus · Signs and symptoms o Fever o Chills[learningradiology.com]
    • Symptoms Typical symptoms include fever, chills, back or belly pain, nausea and vomiting.[ada.com]
    • Signs and symptoms include fever, chills, flank pain, painful and frequent urination, cloudy or bloody urine, and confusion.[fpnotebook.com]
    • Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise.[pathwaymedicine.org]
    Fever
    • You have a fever and chills.[drugs.com]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
    • O Once the woman has been fever-free for 48 hours, give amoxicillin/ampicillin 500 mg by mouth three times a day to complete 14 days of treatment.[books.mcai.org.uk]
    • Common symptoms include back or belly pain, fever, nausea and vomiting.[ada.com]
    High Fever
    • fever ( 103 F) Severe flank or Abdominal Pain Debilitated condition Pregnancy (some cases may be treated outpatient) XVI.[fpnotebook.com]
    • Clinical presentation is fairly specific and classical in most cases, consisting of a rapid onset of high fever and flank pain and tenderness.[radiopaedia.org]
    • Call your health care provider if you have been diagnosed with this condition and new symptoms develop, especially: Decreased urine output Persistent high fever Severe flank pain or back pain Back to Top Prevention Prompt and complete treatment of bladder[nytimes.com]
    • ., renal dysfunction, acidosis) Pregnancy Severe flank or abdominal pain Toxic appearance Unable to take liquids by mouth Very high fever ( 103 F [39.4 C]) Diagnostic Tests URINALYSIS Urine dipstick testing, microscopic urinalysis, or both are commonly[aafp.org]
    Malaise
    • Signs and Symptomology Acute pyelonephritis is a deep infection and patients often display consitutional symptoms such as fever, chills, and malaise.[pathwaymedicine.org]
    • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
    • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary frequency Urinary urgency X.[fpnotebook.com]
    • ., fever, chills, malaise) Gastrointestinal symptoms (e.g., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic[aafp.org]
    Rigor
    • [www.symptoma.com] Rigor Febrile patients commonly exhibit chills or rigor as well, alongside fatigue and weakness.[symptoma.com]
    • URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability.[nytimes.com]
    • Fever is variable but can be high enough to produce rigors.[patient.info]
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  • neurologic
    Headache
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
    • This then followed by pain, loss of appetite, headache.[forerunnershealthcare.com]
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  • gastrointestinal
    Abdominal Pain
    • Proper utilization of sonography and computed tomography in patients with abdominal pain helps to clarify ambiguous diagnoses in an emergency department and avoid unnecessary surgical procedures.[tzuchi.com.tw]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    • . - E Levine, JJ Grantham - American Journal of , 1992 - Am Roentgen Ray Soc Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx Acute pyelonephritis in adults: prediction of mortality[symptoma.com]
    • ., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic tenderness Laboratory tests Urinalysis showing positive[aafp.org]
    • In addition, classic upper urinary tract symptoms to include flank or back pain may be accompanied by systemic symptoms (e.g. fever, chills, abdominal pain, nausea and vomiting).[clinicaladvisor.com]
    Abdominal Tenderness
    • Signs Fever Tachycardia Hypotension Costovertebral angle tenderness Abdominal tenderness (esp. suprapubic tenderness) XI.[fpnotebook.com]
    Acute Abdomen
    • Causes of acute abdomen .[patient.info]
    • . - PF Jones - British medical journal, 1976 - bmj.com Acute abdomen of unknown origin: impact of CT on diagnosis and management - P Taourel, MP Baron, J Pradel, JM Fabre - Abdominal , 1992 - Springer A ecropsy Study of Diabetes Mellitus atal Blacks -[symptoma.com]
    • Diagnoses to Consider in Patients with Flank Pain and Costovertebral Angle Tenderness Disorder Flank pain* Costovertebral angle tenderness* Fever and leukocytosis* Abdominal abscess / / Acute abdomen / / / Acute pyelonephritis Appendicitis / / / Basilar[aafp.org]
    Left Flank Pain
    • Language English Discipline of Urology, FCM - UNICAMP Fifty four year-old female patient comes to Urology office with a complaint of nocturnal fever, episodes of vomiting and left flank pain for 3 months.[fcm.unicamp.br]
    Loss of Appetite
    • Other symptoms include a loss of appetite, passing urine frequently, blood in the urine, and an unusual smell to the urine.[ada.com]
    • This then followed by pain, loss of appetite, headache.[forerunnershealthcare.com]
    Nausea
    • Common symptoms include back or belly pain, fever, nausea and vomiting.[ada.com]
    • Pyelonephritis PANCE Blueprint Genitourinary (6%) Presentation Pearls Diagnostic studies Treatment Patient will present with fever flank Pain nausea and vomiting  CVA tenderness white blood cell casts in urine Patient will present with ( ) CVA Tenderness[smartypance.com]
    • It is characterized by ABDOMINAL PAIN; FEVER; NAUSEA; VOMITING; and occasionally DIARRHEA.[fpnotebook.com]
    • In children, symptoms such as fever, lethargy, flank pain and nausea may be present.[lecturio.com]
    Suprapubic Pain
    • There is unilateral or bilateral loin pain, suprapubic pain or back pain.[patient.info]
    • Diagnosis and differential diagnosis Establishing the diagnosis Clinical signs and symptoms of acute pyelonephritis includes the typical presentation of UTI, to include dysuria, frequency, urgency, hematuria and suprapubic pain.[clinicaladvisor.com]
    • Patients report the classic symptomatology: frequent and urgent urination , pain during the action, hematuria and suprapubic pain .[symptoma.com]
    Vomiting
    • Common symptoms include back or belly pain, fever, nausea and vomiting.[ada.com]
    • You cannot stop vomiting.[drugs.com]
    • Language English Discipline of Urology, FCM - UNICAMP Fifty four year-old female patient comes to Urology office with a complaint of nocturnal fever, episodes of vomiting and left flank pain for 3 months.[fcm.unicamp.br]
    • Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
    • Pyelonephritis PANCE Blueprint Genitourinary (6%) Presentation Pearls Diagnostic studies Treatment Patient will present with fever flank Pain nausea and vomiting  CVA tenderness white blood cell casts in urine Patient will present with ( ) CVA Tenderness[smartypance.com]
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  • musculoskeletal
    Back Pain
    • [www.symptoma.com] more... musculoskeletal Back Pain It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain at the renal level and flank pain.[symptoma.com]
    • Call your health care provider if you have been diagnosed with this condition and new symptoms develop, especially: Decreased urine output Persistent high fever Severe flank pain or back pain Back to Top Prevention Prompt and complete treatment of bladder[nytimes.com]
    • There is unilateral or bilateral loin pain, suprapubic pain or back pain.[patient.info]
    • In addition, classic upper urinary tract symptoms to include flank or back pain may be accompanied by systemic symptoms (e.g. fever, chills, abdominal pain, nausea and vomiting).[clinicaladvisor.com]
    Myalgia
    • Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days.[portal.research.lu.se]
    • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.[cdc.gov]
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  • cardiovascular
    Tachycardia
    • Signs Fever Tachycardia Hypotension Costovertebral angle tenderness Abdominal tenderness (esp. suprapubic tenderness) XI.[fpnotebook.com]
    • Signs of sepsis (eg, tachypnoea, tachycardia, hypotension).[patient.info]
    • Hypotension, tachycardia and low urine output may be seen in association with acute pyelonephritis in pregnancy.[clinicaladvisor.com]
    • ., nausea, vomiting, anorexia, abdominal pain) Physical examination Fever (temperature 100.4 F [38.0 C]), tachycardia, hypotension Costovertebral angle tenderness Possible abdominal or suprapubic tenderness Laboratory tests Urinalysis showing positive[aafp.org]
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  • urogenital
    Cloudy Urine
    • Common symptoms include: a fever greater than 102 F (38.9 C) pain in the abdomen, back, side, or groin painful or burning urination cloudy urine pus or blood in the urine urgent or frequent urination fishy-smelling urine Other symptoms can include: shaking[healthline.com]
    Dysuria
    • Klebsiella § Proteus § Pseudomonas o Exception is S. aureus, which is spread hematogenously · Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus · Signs and symptoms o Fever o Chills o Flank pain o Dysuria[learningradiology.com]
    • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency.[cdc.gov]
    • There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy.[patient.info]
    • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary frequency Urinary urgency X.[fpnotebook.com]
    • Acute Uncomplicated Pyelonephritis Classic triad of symptoms of acute uncomplicated pyelonephritis includes: Fever Costovertebral tenderness Nausea/vomiting It is usually associated with symptoms of cystitis , which include increased frequency, urgency, dysuria[lecturio.com]
    Flank Pain
    • Signs and symptoms include fever, chills, flank pain, painful and frequent urination, cloudy or bloody urine, and confusion.[fpnotebook.com]
    • Definition of Acute Pyelonephritis Acute pyelonephritis is a bacterial infection of the renal pelvis and the renal parenchyma with fever, flank pain and bacteriuria .[urology-textbook.com]
    • [www.symptoma.com] Flank Pain It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain at the renal level and flank pain .[symptoma.com]
    • Flank pain is nearly universal, and its absence should raise suspicion of an alternative diagnosis.[aafp.org]
    • Pyelonephritis PANCE Blueprint Genitourinary (6%) Presentation Pearls Diagnostic studies Treatment Patient will present with fever flank Pain nausea and vomiting  CVA tenderness white blood cell casts in urine Patient will present with ( ) CVA Tenderness[smartypance.com]
    Hematuria
    • [www.symptoma.com] Hematuria Approximately 1/3 of female patients with pyelonephritis exhibit the symptom of hematuria ; should the patient be male, an investigation of other causes of hematuria should promptly be investigated.[symptoma.com]
    • Labs Urinalysis Leukocyte esterase or nitrite positive Microscopic Hematuria may be present (contrast with Gross Hematuria in Acute Cystitis ) Microscopic examination may show WBC casts Consider urine Gram Stain where available Gram Positive Cocci suggests[fpnotebook.com]
    • Urinalysis will show bacteria, pyuria, and often hematuria.[pathwaymedicine.org]
    • Hematuria and suprapubic discomfort are less common.[cdc.gov]
    Urinary Incontinence
    • incontinence and urinary infection - C Dawson, H Whitfield - BMJ, 1996 - bmj.com Conn's Current Therapy 2008: Text with Online Reference - RE Rakel, ET Bope - 2007 - lavoisier.fr 6 Acute renal failure in pregnancy - N Pertuiset, JP Grünfeld - Baillière's[symptoma.com]
    Urinary Urgency
    • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency.[cdc.gov]
    • Symptoms Fever Chills and malaise Flank pain Nausea and Vomiting Acute Cystitis symptoms Dysuria Urinary frequency Urinary urgency X.[fpnotebook.com]
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  • Workup

    A detailed medical history and clinical examination, alongside confirmation by urinalysis usually suffice in order to diagnose acute pyelonephritis. Radiologic depiction is usually employed in infants and children or adults who do not manifest characteristic symptoms. Should the symptomatology match the typical clinical picture of acute pyelonephritis, the analysis of the urine is expected to produce the following results to confirm an infection:

    A nitrite test can also be used; nevertheless, it can be falsely negative in various cases. A urine culture is also mandatory in order to eliminate antibiotic resistance. A blood culture can confirm the bacterial strain, should the pathogens have reached the renal parenchyma through the bloodstream.

    A physician may perform imaging techniques if a patient continues to deteriorate despite treatment, if toxicity persists for >72 hours and if fever does not subside after 2 days. The optimal imaging technique is considered to be the contrast-enhanced helical/spiral computed tomography (CECT). Should it reveal a possible nephrolithiasis, a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis [9].

    Laboratory

    Serum
    Abnormal Renal Function
    • Spontaneous resolution of the abnormal renal function should be expected as the acute infection clears, although there is some evidence that a minority of women will have permanent renal impairment following a bout of pyelonephritis in pregnancy.[clinicaladvisor.com]
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  • Urine
    Pyuria
    • . · Clinical Findings o CBC § Elevated white blood cell count. o Urinalysis § Bacteriuria § Pyuria § White blood cell casts o Acute pyelonephritis is clinical diagnosis, § Radiographic imaging is used to evaluate underlying pathology § Rule out any complications[learningradiology.com]
    • Urinalysis will show bacteria, pyuria, and often hematuria.[pathwaymedicine.org]
    • Laboratory Urine Pyuria Should the symptomatology match the typical clinical picture of acute pyelonephritis, the analysis of the urine is expected to produce the following results to confirm an infection: Considerable pyuria : 5-10 WBCs per hpf Proteinuria[symptoma.com]
    • Diagnosis Fever over 100.4 F May be absent early in course Not uniformly present in elderly (only in 80%) Not uniformly present in catheter-associated UTI Flank pain Urinalysis with bacteriuria and pyuria XII.[fpnotebook.com]
    • Diagnosis & Laboratory Investigations of Kidney Infection Blood and Urine Examination in Pyelonephritis Acute pyelonephritis classically shows the presence of WBC casts, hematuria along with pyuria and bacteriuria .[lecturio.com]
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  • Microbiology
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  • Imaging

    X-ray
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  • Treatment

    Prompt treatment of acute pyelonephritis is the key to achieving optimal therapeutic results. Since blood and urine cultures need some days to produce the results and pyelonephritis should be treated as early as possible, empirical treatment is usually administered from the start, which may be subject to adaptations if the cultures show a resistant microorganism. Local studies of pathogen resistance should be consulted prior to choosing the antimicrobial agent. Patients may need to be hospitalized, receive parenteral treatment and then complete their regime with oral agents [10] or could be treated at home from the beginning. A patient can be allowed to remain at home and receive oral treatment if they are in a good health status other than pyelonephritis, if they can abide by the doctor's direction, they display no septic phenomena or further complications.

    Empirical treatment includes the administration of a selection of the following agents:

    • Meropenem 
    • Imipenem
    • Ampicillin and an aminoglycoside
    • Piperacillin-tazobactam
    • Ticarcillin-clavulanate

    A penicillin allergy prompts its replacement with vancomycin. Hospital therapy is continued for 10 to 14 days, starting with IV administration of antibiotics fro at least 1 or 2 days or until the patient's condition ameliorates.

    Prognosis

    An episode of acute pyelonephritis is a treatable condition, which, if addressed appropriately, can heal completely; if mistreated or untreated, however, it can cause serious damage and threaten the kidney and potentially the life of the patient as well.

    Healthy individuals, both men and non-pregnant women, tend to recover to a full extent with no renal impairment, given that their health status is other than that normal. On the other hand, pregnant women do run a higher risk of going into labor prematurely and patients over the age of 65, immunodeficient people and people with a generally poor status of health display an increased mortality. Patients with an underlying diabetes mellitus were also shown to suffer from severer attacks of pyelonephritis and have increased mortality [8].

    Complications

    Acute Glomerulonephritis
    • glomerulonephritis acute nephritis Type 1 Excludes acute tubulo-interstitial nephritis ( N10 ) nephritic syndrome NOS ( N05.- ) Nephritis, nephritic (albuminuric) (azotemic) (congenital) (disseminated) (epithelial) (familial) (focal) (granulomatous)[icd10data.com]
    Acute Kidney Failure
    • Other complications include: recurring kidney infections the infection spreading to areas around the kidneys acute kidney failure kidney abscess Prevention Preventing pyelonephritis Pyelonephritis can be a serious condition.[healthline.com]
    • Back to Top Possible Complications Acute kidney failure Kidney infection returns Infection around the kidney (perinephric abscess) Severe blood infection (sepsis) Back to Top When to Contact a Medical Professional Call your health care provider if you[nytimes.com]
    Appendicitis
    • Appendicitis was suspected initially.[tzuchi.com.tw]
    • Differential diagnosis: Pelvic inflammatory disease (PID) , appendicitis , urolithiasis, biliary tract disease, acute pancreatitis, basal pneumonia.[hopkinsguides.com]
    • […] for 10 days in the treatment of acute pyelonephritis - HA Klausner, P Brown, J Peterson - Current Medical , 2007 - informahealthcare.com Acute lobar nephronia: a review - MH RATHORE, A LUISIRI, LL BARTON - Pediatrics, 1991 - Am Acad Pediatrics Acute appendicitis[symptoma.com]
    • Diagnoses to Consider in Patients with Flank Pain and Costovertebral Angle Tenderness Disorder Flank pain* Costovertebral angle tenderness* Fever and leukocytosis* Abdominal abscess / / Acute abdomen / / / Acute pyelonephritis Appendicitis / / / Basilar[aafp.org]
    Chronic Pyelonephritis
    • Chronic Pyelonephritis Scarring of the glomeruli and tubular atrophy are characteristic of chronic pyelonephritis.[lecturio.com]
    • Chronic pyelonephritis is more common in children than in adults.[healthline.com]
    • Presentation Chronic pyelonephritis is often asymptomatic.[patient.info]
    • General Acute and chronic pyelonephritis Pseudomonas abscess End of Kidney non-tumor Tubular and interstitial diseases Acute pyelonephritis Ref Updated: 8/16/12 This information is intended for physicians and related personnel, who understand that medical[pathologyoutlines.com]
    • Chronic pyelonephritis may require long-term antibiotic therapy.[nytimes.com]
    Constipation
    • Extrinsic obstruction occurs with chronic constipation (particularly in children), prostatic swelling/mass (eg, hypertrophy, infection, cancer), and retroperitoneal mass.[emedicine.medscape.com]
    Endometritis
    • However, blood cultures may be the only method of identifying the causative organism in cases of suspected acute pyelonephritis that turn out to be another disorder, such as endometritis, intraabdominal or psoas abscess, or cholangitis.[aafp.org]
    Hydronephrosis
    • Pictures Hydronephrosis: Hydronephrosis, Macro, autopsy (71055) Unilateral hydronephrosis, Macro, autopsy (71056) Hydronephrosis, Macro, autopsy (71057) Hydronephrosis, Macro, autopsy (71058) Hydronephrosis, hydroureter, Macro, autopsy (71054) Kidney[atlases.muni.cz]
    • […] with ureteropelvic junction obstruction N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified N13.2 Hydronephrosis with renal and ureteral calculous obstruction Reimbursement claims with a date of service on or after October 1, 2015[icd10data.com]
    • […] in urine Patient will present with ( ) CVA Tenderness If severe symptoms or unable to take PO will need to be hospitalized White blood cell casts in urine is pathognomonic pyelonephritis If complicated pyelonephritis order a renal ultrasound may show hydronephrosis[smartypance.com]
    • . · Complications o Abscess o Emphysematous pyelonephritis § Most often occurs in diabetics · Can produce gas in the collecting system and renal parenchyma · Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped[learningradiology.com]
    • Symptomatic physiologic hydronephrosis in pregnancy: incidence, complications and treatment.[revistanefrologia.com]
    Nephrolithiasis
    • Risk Factors: Complicated Pyelonephritis (with higher risk of complications such as abscess, Antibiotic Resistance) Age under 1 or over 60 years Abnormality (Polycystic Kidney , Vesicoureteral reflux) Obstruction ( Nephrolithiasis , BPH, tumor) Immunocompromised[fpnotebook.com]
    • "Chapter 135: Approach to the Paient with Nephrolithiasis".[en.wikipedia.org]
    • [www.symptoma.com] Nephrolithiasis Should it reveal a possible nephrolithiasis , a computed tomography (CT) scan and urogram need to be carried out for fear of hydronephrosis.[symptoma.com]
    • However, if the patient continues to mount fevers more than 72 hours after inpatient admission and appropriate parenteral antibiotics are initiated, a renal ultrasound should be obtained to evaluate for nephrolithiasis or renal abscess.[clinicaladvisor.com]
    Pelvic Inflammatory Disease
    • Pelvic inflammatory disease .[patient.info]
    • Differential diagnosis: Pelvic inflammatory disease (PID) , appendicitis , urolithiasis, biliary tract disease, acute pancreatitis, basal pneumonia.[hopkinsguides.com]
    • inflammatory disease / / Pulmonary infarctions / Renal corticomedullary necrosis Renal vein thrombosis Retroperitoneal disorders (e.g., hemorrhage, abscess) / / / Shingles Splenic abscess or infarct / Urinary tract obstruction / Vascular pathology Enlarge[aafp.org]
    Perinephric Abscess
    • Complications of acute pyelonephritis : Papillary necrosis - frequently seen in diabetics and those with urinary obstruction Pyonephrosis Perinephric abscess Macroscopy : The size of the affected kidneys is normal or slighted enlarged.[pathologyatlas.ro]
    • . : Perinephric abscess, current concepts.[fcm.unicamp.br]
    • Perinephric abscess (more common if there is urinary tract abnormality).[patient.info]
    • Complications Perinephric abscess Emphysema tous Pyelonephritis Occurs in older women with Diabetes Mellitus Infection produces intraparenchymal gas Associated with papillary necrosis and Renal Failure Urinary Tract Infection due to obstruction Associated[fpnotebook.com]
    • Back to Top Possible Complications Acute kidney failure Kidney infection returns Infection around the kidney (perinephric abscess) Severe blood infection (sepsis) Back to Top When to Contact a Medical Professional Call your health care provider if you[nytimes.com]
    Perinephritis
    • Complications of acute pyelonephritis : Papillary necrosis - frequently seen in diabetics and those with urinary obstruction Pyonephrosis Perinephric abscess Macroscopy : The size of the affected kidneys is normal or slighted enlarged.[pathologyatlas.ro]
    • […] and renal parenchyma · Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped areas of low attenuation secondary to decreased perfusion (CT) o Loss of the ability to distinguish the corticomedullary border (CT) o Perinephric[learningradiology.com]
    • Perinephric abscess (more common if there is urinary tract abnormality).[patient.info]
    • If such an abscess then ruptures into the perinephric space, a perirenal abscess is formed.[guidelinecentral.com]
    • . : Perinephric abscess, current concepts.[fcm.unicamp.br]
    Preterm Labor
    • If someone comes in with acute pyelonephritis and preterm labor, you don't want to use tocolytics such as terbutaline because terbutaline itself is associated with increased risk of pulmonary edema, which in turn can result in adult respiratory distress[thefreedictionary.com]
    • More research should be done to elucidate each risk factor for preterm labor independently.[clinicaladvisor.com]
    Proteinuria
    • Should the symptomatology match the typical clinical picture of acute pyelonephritis , the analysis of the urine is expected to produce the following results to confirm an infection : Considerable pyuria : 5-10 WBCs per hpf Proteinuria ; up to 2 g per[symptoma.com]
    • Urine: leukocytes ( ), proteinuria ( ), urea 55mg/dl, creatinine 1.2mg/dl, total proteins 5.1g/dl and CRP 69mg/dl.[revistanefrologia.com]
    • A study of nephropathy resulted in an association of the 869 CC genotype with heavy proteinuria and a higher score of mesangial cell proliferation [ 84 ]. 2.5.5.[intechopen.com]
    Renal Abscess
    • Renal abscess in a young woman after delivery.[revistanefrologia.com]
    • Jr and Perkins T. : Presentation, diagnosis and treatment of renal abscesses.[fcm.unicamp.br]
    • Rarely, the kidney may be seeded haematogenously, in which case renal abscesses develop rather than pyelonephritis.[radiopaedia.org]
    • Renal abscess has a favorable prognosis after drainage and antibiotic treatment.[urology-textbook.com]
    • abscess and severe infection Images: Related links to external sites (from Bing) Ontology: Pyelonephritis (C0034186) Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the kidney.[fpnotebook.com]
    Renal Colic
    • For example, if renal colic is suspected then a non-contrast scan is often required to assess for renal calculi.[radiopaedia.org]
    • Acute papillary necrosis, which is more likely in the elderly and those with diabetes (suggested by associated symptoms of renal colic).[patient.info]
    • colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis - R Andresen, HEH Wegner - Urologia internationalis, 1997 - content.karger.com Use of Urinary α sub 1-Microglobulin and sup 99m Tc DMSA Scintigraphy in[symptoma.com]
    Renal Papillary Necrosis
    • You're also at increased risk for a kidney infection if you have any of the following conditions: Backflow of urine into the ureters or kidney pelvis Kidney stones Ostructive uropathy Renal papillary necrosis You are also more likely to get a kidney infection[nytimes.com]
    Septic Shock
    • Key Words: acute pyelonephritis ; computed tomography ; septic shock[kjccm.org]
    • Shock Possible complications resulting from acute pyelonephritis include septic phenomena or even septic shock , renal scarring, abscesses located on the kidney or on adjacent tissue and failure of multiple organs.[symptoma.com]
    • A serious complication of urosepsis is septic shock and disseminated intravascular coagulation (DIC), and these patients require close monitoring in an intensive care unit, often with pulmonary artery catheterization.[clinicaladvisor.com]
    • Leukocytosis and resistance to septic shock in intercellular adhesion molecule 1-deficient mice.[intechopen.com]
    Septicemia
    • Infection spreads through the blood-stream from distant foci (bronchopneumonia, otitis, endocarditis or septicemia) causing abscesses.[pathologyatlas.ro]
    • Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%).[journals.lww.com]
    Shock
    • Key Words: acute pyelonephritis ; computed tomography ; septic shock[kjccm.org]
    • O If shock is present or suspected, initiate immediate ABC treatment.[books.mcai.org.uk]
    • The elderly, infants, and persons with a weakened immune system have an increased risk for developing shock and a severe blood infection called sepsis .[nytimes.com]
    • [www.symptoma.com] Shock Possible complications resulting from acute pyelonephritis include septic phenomena or even septic shock , renal scarring, abscesses located on the kidney or on adjacent tissue and failure of multiple organs.[symptoma.com]
    • Leukocytosis and resistance to septic shock in intercellular adhesion molecule 1-deficient mice.[intechopen.com]
    Spinal Epidural Abscess
    • . - WD McDonough, CM Sandler, GS Benson - The Journal of urology, 1981 - ncbi.nlm.nih.gov Acute spinal epidural abscess.[symptoma.com]
    Ureterolithiasis
    • "Diagnosis and Management of Acute Ureterolithiasis: CT Is Truth" (PDF) .[en.wikipedia.org]
    • Acute Ureterolithiasis: Nonenhanced Helical CT Findings of Perinephric Edema for Prediction of Degree of Ureteral Obstruction1 - IC Boridy, A Kawashima, SM Goldman, CM Sandler - Radiology, 1999 - radiology.rsna.org Acute pyelonephritis as a cause of late[symptoma.com]
    • Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness.[aafp.org]
    Urosepsis
    • Urosepsis is a potentially fatal complication that results from bacteremia.[clinicaladvisor.com]
    • Complications of obstruction with superimposed infection include hydronephrosis, pyonephrosis, urosepsis, and xanthogranulomatous pyelonephritis .[emedicine.medscape.com]
  • more...
  • Etiology

    The greater majority of pyelonephritis cases are triggered by bacteria, which have infiltrated the renal parenchyma via the lower parts of the urinary tract. A crucial risk factor that increases susceptibility to such a condition is anatomic variability: strictures at any part of the lower tract or ureters increase the possibility of developing a renal inflammation. This risk factor primarily affects men. The condition frequently affects young women and women who have undergone catheterization.

    Another pathway, through which bacteria can infiltrate the kidney, is the bloodstream itself. Aggressive pathogens such as Staphylococcus aureus, pseudomonas aeruginosa and various Candida species are known to posses the ability to enter the renal parenchyma in such a way.

    Epidemiology

    Studies conducted in the USA confirmed that women tend to be more frequently affected by pyelonephritis than men. Researchers observed that, per year, around 16 cases of acute pyelonephritis were diagnosed amongst 10,000 women, in contradistinction to a considerably lower number, 3-4, per 10,000 men [3]. Even in women, the susceptibility to pyelonephritis varies with age: incidence increases at the periods of 0-4 years old, 15 to 35 years old and then again after the 80th year of age [3]. Treatment of acute pyelonephritis costs approximately $2.14 billion annually [3] [4].

    Pregnant women run a higher risk of being affected by acute pyelonephritis. Data exhibited a staggering 20-30% of pyelonephritis cases in pregnant women, resulting from asymptomatic bacteriuria, for which the patients received no therapy. Women are also more frequently hospitalized with acute pyelonephritis than men, at a rate of 5:1, but do, however, maintain a lower mortality rate [5].

    Pyelonephritis affects people of all ethnicities and its incidence seems to fluctuate additionally, according to the season. July, August and September were shown to be the months with an increased incidence of acute pyelonephritis, according to a study conducted in the state of Washington.

    Sex distribution
    Age distribution

    Pathophysiology

    A lower urinary tract infection (lower UTI) that is complicated with the ascendance of bacteria to the kidneys causes acute pyelonephritis; it is possible to outline a partial profile of patients who are in higher risk of developing such a condition, based on patient characteristics and bacterial traits [6].

    The bloodstream pathway is another possibility for bacterial infiltration of the kidney. Bacteremia due to gram (+) pathogens, combined with other underlying systemic conditions or iatrogenic immunosuppression can lead to acute pyelonephritis, where the bacteria have been transferred to the kidney parenchyma through the bloodstream. This pathway, however, is reserved almost exclusively for the immunodeficient.

    Most cases of lower or upper UTI can be traced back to the Escherichia coli pathogen, and more specifically, the uropathogenic E. coli (UPEC), which is one of the bacterium's strains. This bacterium latches on to the epithelial layers, causing a glycosphingolipid- and TLR4-mediated inflammation. This results to the activation of the immune system; chemokines such as IL-8 are activated, and connect to the interleukin 8 receptor (CXCR1). As a result, polymorphonuclear leukocytes are allowed to access the urine.

    Infection is initiated at the pelvis, proceeding to the medulla and the cortex as it expands, while separate non-infected regions may still appear inbetween. An abscess may form and other papillary necrosis is reserved for patients with an underlying systemic disease (diabetes, analgesic neuropathy, sickle cell disease). Men who have an anatomic urinary tract obstruction, including prostatitis and hypertrophy, are in increased danger of suffering from acute pyelonephritis [7].

    Prevention

    Pyelonephritis can be prevented by adaptations in one's routine and behavior, in order to eliminate the possibility of being affected by a urinary tract infection. Contraceptive behavior should be reevaluated, frequent urination is encouraged and any case of cystitis should be identified and treated early, so as to avoid its being complicated with acute pyelonephritis. Patients who do proceed to these adaptations but still experience recurrent phenomena of UTI or pyelonephritis or do not respond to appropriate treatment should be examined for the existence of an obstructing anatomic variation.

    Specifically women who are affected by a urinary tract infection more than three times per year should consider the following measures:

    • Drinking larger amounts of fluids, preferably water.
    • Urinating frequently.
    • Urinating before and after coitus.
    • Avoiding the use of a diaphragm or spermicide.
    • Wiping from the front to the back after defecation.
    • Prophylactic antibiotics administered either continuously or after sexual intercourse. This scheme is recommended after failure of the aforementioned methods.

    Proper hydration is generally the key to avoiding frequent urinary tract infections and reducing the risk of acute pyelonephritis.

    Summary

    Acute pyelonephritis poses a considerable threat on the life of the affected patient and the functionality of the kidneys, as it can induce severe renal impairment. Possible complications resulting from acute pyelonephritis include septic phenomena or even septic shock, renal scarring, abscesses located on the kidney or on adjacent tissue and failure of multiple organs. Individuals who are immunosuppressed run a significantly higher risk of developing any of those complications [1] [2].

    In the majority of the cases, acute pyelonephritis is preceded by an episode of infection of the urinary tract's lower parts. Patients report the classic symptomatology: frequent and urgent urination, pain during the action, hematuria and suprapubic pain. It is also possible that a patient first becomes symptomatic with symptoms originating from the acute pyelonephritis itself, such as back pain at the renal level and flank pain. General signs of inflammation may accompany both cases and patients may be febrile and experience nausea, frequent vomiting and chills. Acute pyelonephritis may also present with symptoms that are non-specific; therefore, clinical doctors should be always suspicious in cases of inflammations which are hard to trace. 

    Patient Information

    Acute pyelonephritis is an inflammation of one or both kidneys, caused by a bacterial infection. The bacteria may ascend to the kidneys from lower parts of the urinary tract, such as the bladder, due to a previous infection affecting those parts (cystitis).

    The bacterium that most commonly causes cystitis and subsequent pyelonephritis is the Escherichia coli, normally found in the intestines, excrement and transiently the anal area. Poor genital hygiene or wrong toilet habits may lead to these bacteria entering the bladder and further moving up to the kidneys.

    Women tend to be more frequently affected by pyelonephritis that men. Generally, there are sub-categories of people who run a higher risk of developing pyelonephritis, such as people who suffer from diabetes mellitus, transplant receivers, HIV patients, people who receive medication that weakens their immune system and pregnant women.

    Pyelonephritis produces symptoms that involve fever with chills, pain at the back (low), nausea and vomiting. The condition will be diagnosed based on the symptomatology, urine test and urine culture. A urine test helps to confirm the inflammation, as it can detect the number of white blood cells currently present in the urine and the red blood cells. A urine culture will reveal the bacterium responsible for the inflammation. Treatment should be administered promptly in order to avoid possible complications and may be carried out in a hospital or at home, depending on the person's general health status and clinical manifestations. Treatment regimes last for 6-14 days.

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    References

    1. Bass PF 3d, Jarvis JA, Mitchell CK. Urinary tract infections. Prim Care. 2003;30:41–61.
    2. Bergeron MG. Treatment of pyelonephritis in adults. Med Clin North Am. 1995;79:619–49.
    3. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007 Aug 1. 45(3):273-80.
    4. National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). Kidney and Urologic Diseases Statistics for the United States. Available at http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#urologic. Accessed: October 31, 2011.
    5. Foxman B, Klemstine KL, Brown PD. Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality. Ann Epidemiol. 2003;13:144–50.
    6. Mazaki-Tovi S, Vaisbuch E, Romero R, et al. Maternal plasma concentration of the pro-inflammatory adipokine pre-B-cell-enhancing factor (PBEF)/visfatin is elevated in pregnant patients with acute pyelonephritis. Am J Reprod Immunol. 2010 Mar 1. 63(3):252-62.
    7. Stamm WE. Urinary tract infections and pyelonephritis. In: Harrison TR, Braunwald E, eds. Harrison’s Principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001:1620–6.
    8. Kofteridis DP, Papadimitraki E, Mantadakis E, et al. Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis. J Am Geriatr Soc. 2009 Nov. 57(11):2125-8.
    9. Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi.
    10. van Nieuwkoop C, van't Wout JW, Spelt IC, et al. Prospective cohort study of acute pyelonephritis in adults: safety of triage towards home based oral antimicrobial treatment. J Infect. 2010 Feb. 60(2):114-21.

    • Acute graft pyelonephritis and long-term kidney allograft outcome - M Giral, G Pascuariello, G Karam, M Hourmant - Kidney , 2002 - nature.com
    • A case of fever and unexplained acute renal failure - V Sakhuja, R Agarwal, N Kalra - Indian journal of nephrology, 2008 - ncbi.nlm.nih.gov
    • 99m Tc-DMSA scintigraphy in acute urinary tract infection in children - M Verboven, M Ingels, M Delree, A Piepsz - Pediatric radiology, 1990 - Springer
    • Antibiotics for acute pyelonephritis in children - EM Hodson, NS Willis, JC Craig - Cochrane Database Syst , 2007 - Wiley Online Library
    • Acute pyelonephritis in pregnancy: An anterospective study. - LC Gilstrap 3rd, FG Cunningham - Obstetrics and , 1981 - ukpmc.ac.uk
    • A review of the complications of burns, their origin and importance for illness and death - S Sevitt - J Trauma, 1979 - ukpmc.ac.uk
    • ADDITIONAL TREATMENT - INP CONSIDERATIONS - The 5-Minute Consult Clinical , 2012 - books.google.com
    • Bilateral emphysematous pyelonephritis - A Zabbo, JE Montie, KL Popowniak, AJ Weinstein - Urology, 1985 - Elsevier
    • Antibiotic treatment for acute 'uncomplicated'or 'primary'pyelonephritis: a systematic,'semantic revision' - GB Piccoli, V Consiglio, L Colla, P Mesiano - International journal of , 2006 - Elsevier
    • Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis - MI Prieto-Nieto, JP Perez-Robledo - Annals of vascular , 2004 - Elsevier
    • Acute uncomplicated urinary tract infection in women - SD Fihn - New England Journal of Medicine, 2003 - Mass Medical Soc
    • A STUDY ON THE EFFICACY OF HOMOEOPATHIC MEDICINES IN THE MANAGEMENT OF DIABETES MELLITUS SATISFYING THE CRITERIA OF - DRR ABRAHAM - similima.com
    • A survey of 499 patients with acute anuric renal insufficiency: Causes, treatment, complications and mortality - JT Balsløv, HE Jørgensen - The American journal of medicine, 1963 - Elsevier
    • A pathological study of five cases of pyelonephritis in the newborn - KA Porter, MMC Giles - Archives of disease in childhood, 1956 - adc.bmj.com
    • Acute pyelonephritis in adults: prediction of mortality and failure of treatment - SP Efstathiou, AV Pefanis, DI Tsioulos - Archives of internal , 2003 - Am Med Assoc
    • Of human type O erythrocytes, hemolysin production, and serogrouping of Escherichia coli isolates from patients with acute pyelonephritis, cystitis, and asymptomatic - CP Green, VL Thomas - Infection and immunity, 1981 - Am Soc Microbiol
    • Calcified renal stones and cyst calcifications in autosomal dominant polycystic kidney disease: clinical and CT study in 84 patients. - E Levine, JJ Grantham - American Journal of , 1992 - Am Roentgen Ray Soc
    • Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    • Acute pyelonephritis in adults: prediction of mortality and failure of treatment - SP Efstathiou, AV Pefanis, DI Tsioulos - Archives of internal , 2003 - Am Med Assoc
    • Acute flank pain: comparison of unenhanced helical CT and ultrasonography in detecting causes other than ureterolithiasis - O Catalano, A Nunziata, F Sandomenico, A Siani - Emergency radiology, 2002 - Springer
    • Diagnosis and management of acute pyelonephritis in adults - K Ramakrishnan, DC Scheid - Am Fam Physician, 2005 - drplace.com
    • Abdominal pain during pregnancy - MS Cappell, D Friedel - Gastroenterology clinics of , 2003 - medicina.iztacala.unam.mx
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute - M Etienne, P Chavanet, L Sibert, F Michel - BMC infectious , 2008 - biomedcentral.com
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • Active observation in management of acute abdominal pain in childhood. - PF Jones - British medical journal, 1976 - bmj.com
    • Acute abdomen of unknown origin: impact of CT on diagnosis and management - P Taourel, MP Baron, J Pradel, JM Fabre - Abdominal , 1992 - Springer
    • A ecropsy Study of Diabetes Mellitus atal Blacks - KD Bhoola - Brit. Med. J, 1972 - archive.samj.org.za
    • Acute pyelonephritis in pregnancy: a retrospective study - P Sharma, L Thapa - Australian and New Zealand journal of , 2007 - Wiley Online Library
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • Acute pyelonephritis in adults: prediction of mortality and failure of treatment - SP Efstathiou, AV Pefanis, DI Tsioulos - Archives of internal , 2003 - Am Med Assoc
    • A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy - DA Wing, CM Hendershott, L Debuque, LK Millar - Obstetrics & Gynecology, 1998 - Elsevier
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • Acute graft pyelonephritis and long-term kidney allograft outcome - M Giral, G Pascuariello, G Karam, M Hourmant - Kidney , 2002 - nature.com
    • Of human type O erythrocytes, hemolysin production, and serogrouping of Escherichia coli isolates from patients with acute pyelonephritis, cystitis, and asymptomatic - CP Green, VL Thomas - Infection and immunity, 1981 - Am Soc Microbiol
    • Contrast-enhanced CT for acute flank pain caused by acute renal artery occlusion - V Amilineni, DF Lackner, WS Morse - American Journal of , 2000 - Am Roentgen Ray Soc
    • A trial of levofloxacin 750 mg once daily for 5 days versus ciprofloxacin 400 mg and/or 500 mg twice daily for 10 days in the treatment of acute pyelonephritis - HA Klausner, P Brown, J Peterson - Current Medical , 2007 - informahealthcare.com
    • Acute lobar nephronia: a review - MH RATHORE, A LUISIRI, LL BARTON - Pediatrics, 1991 - Am Acad Pediatrics
    • Acute appendicitis in the pregnant patient - IL Tamir, FS Bongard, SR Klein - The American journal of surgery, 1990 - Elsevier
    • Cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases - K Gupta, TM Hooton, KG Naber, B Wullt - Clinical Infectious , 2011 - cid.oxfordjournals.org
    • Acute renal and perirenal infections. - JA Evans, MA Meyers, MA Bosniak - Seminars in roentgenology, 1971 - ncbi.nlm.nih.gov
    • Acute osteomyelitis of a vertebral body following compression fracture - RF ATSATT - The Journal of Bone & Joint Surgery, 1939 - jbjs.org
    • And computerized tomography: diagnostic yield in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis - R Andresen, HEH Wegner - Urologia internationalis, 1997 - content.karger.com
    • Use of Urinary α< sub> 1-Microglobulin and< sup> 99m Tc DMSA Scintigraphy in the Diagnosis and Follow-Up of Acute Pyelonephritis and Cystitis in - K Everaert, A Raes, P Hoebeke, W Samijn - European , 1998 - content.karger.com
    • Acute pyelonephritis in adults: prediction of mortality and failure of treatment - SP Efstathiou, AV Pefanis, DI Tsioulos - Archives of internal , 2003 - Am Med Assoc
    • Acute pyelonephritis in pregnancy - JB Hill, JS Sheffield, DD McIntire - Obstetrics & , 2005 - journals.lww.com
    • Use of Urinary α< sub> 1-Microglobulin and< sup> 99m Tc DMSA Scintigraphy in the Diagnosis and Follow-Up of Acute Pyelonephritis and Cystitis in - K Everaert, A Raes, P Hoebeke, W Samijn - European , 1998 - content.karger.com
    • Acute flank pain secondary to urolithiasis: Radiologic evaluation and alternate diagnoses - G Jindal, P Ramchandani - Radiologic Clinics of North America, 2007 - Elsevier
    • 99m Technetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings - B Jakobsson, L Nolstedt, L Svensson, S Söderlundh - Pediatric , 1992 - Springer
    • Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection - KY Lin, NT Chiu, MJ Chen, CH Lai, JJ Huang - Pediatric , 2003 - Springer
    • Acute pyelonephritis in pregnancy - JB Hill, JS Sheffield, DD McIntire - Obstetrics & , 2005 - journals.lww.com
    • Analgesic nephropathy: etiology, clinical syndrome, and clinicopathologic correlations in Australia - RS Nanra, J Stuart-Taylor, AH De Leon, KH White - Kidney Int, 1978 - nature.com
    • Association between urinary symptoms at 7 years old and previous urinary tract infection. - A Hellström, E Hanson, S Hansson - Archives of disease in , 1991 - adc.bmj.com
    • Adult respiratory distress syndrome in pregnancy: report of three cases and review of the literature - VA Catanzarite, D Willms - Obstetrical & gynecological survey, 1997 - journals.lww.com
    • Acute focal bacterial nephritis: focal pyelonephritis that may simulate renal abscess. - WD McDonough, CM Sandler, GS Benson - The Journal of urology, 1981 - ncbi.nlm.nih.gov
    • Acute spinal epidural abscess. Observations from fourteen cases. - GE Phillips, A Jefferson - Postgraduate Medical Journal, 1979 - pmj.bmj.com
    • Chronic pyelonephritis and arterial hypertension - AM Butler - Journal of Clinical Investigation, 1937 - ncbi.nlm.nih.gov
    • Computed tomography in acute pyelonephritis - E Senn, W Zaunbauer, K Bandhauer - British journal of , 1987 - Wiley Online Library
    • Abdominal amyloidosis: spectrum of radiological findings - SH Kim, JK Han, KH Lee, HJ Won, KW Kim, JS Kim - Clinical radiology, 2003 - Elsevier
    • Current medical diagnosis & treatment 2010 - SJ McPhee, MA Papadakis, MW Rabow - 2010 - media.matthewsbooks.com.s3.
    • Acute Ureterolithiasis: Nonenhanced Helical CT Findings of Perinephric Edema for Prediction of Degree of Ureteral Obstruction1 - IC Boridy, A Kawashima, SM Goldman, CM Sandler - Radiology, 1999 - radiology.rsna.org
    • Acute pyelonephritis as a cause of late transplant dysfunction - DM Gillum, SP Kelleher - The American journal of medicine, 1985 - Elsevier
    • Acute renal failure associated with acute pyelonephritis and consumption of non-steroidal anti-inflammatory drugs. - LK Atkinson, TH Goodship, MK Ward - British medical journal ( , 1986 - ncbi.nlm.nih.gov
    • Argentaffin Cell Carcinoma of the Rectum: Two Case Reports - ER Smith - Australian and New Zealand Journal of Surgery, 1970 - Wiley Online Library
    • Acute Nontraumatic Abdominal Pain in Adult Patients: Abdominal Radiography Compared with CT Evaluation1 - SH Ahn, WW Mayo-Smith, BL Murphy, SE Reinert - , 2002 - radiology.rsna.org
    • Of human type O erythrocytes, hemolysin production, and serogrouping of Escherichia coli isolates from patients with acute pyelonephritis, cystitis, and asymptomatic - CP Green, VL Thomas - Infection and immunity, 1981 - Am Soc Microbiol
    • Of human type O erythrocytes, hemolysin production, and serogrouping of Escherichia coli isolates from patients with acute pyelonephritis, cystitis, and asymptomatic - CP Green, VL Thomas - Infection and immunity, 1981 - Am Soc Microbiol
    • Acute pyelonephritis in pregnancy - JB Hill, JS Sheffield, DD McIntire - Obstetrics & , 2005 - journals.lww.com
    • Of cefuroxime administration on endotoxin (LPS) and tumour necrosis factor-α (TNFα) blood levels in patients suffering from acute pyelonephritis: a preliminary report - EJ Giamarellou-Bourboulis, J Perdios, M Lelekis - International journal of , 1999 - Elsevier
    • ABC of Urology: Urinary incontinence and urinary infection - C Dawson, H Whitfield - BMJ, 1996 - bmj.com
    • Conn's Current Therapy 2008: Text with Online Reference - RE Rakel, ET Bope - 2007 - lavoisier.fr
    • 6 Acute renal failure in pregnancy - N Pertuiset, JP Grünfeld - Baillière's clinical obstetrics and gynaecology, 1994 - Elsevier

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