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Chronic Pyelonephritis

Chronic pyelonephritis is a long-standing renal disorder characterized by tubulointerstitial inflammation with cortical scarring that eventually may result in end-stage renal disease. It includes variants like xanthogranulomatous pyelonephritis and emphysematous pyelonephritis. Diagnosis is based on renal function tests, urinalysis, urine culture, histopathology and radiological investigations.


Presentation

Chronic pyelonephritis (CP) is marked by chronic renal tubulointerstitial inflammation which leads to scarring within the renal cortex and calyceal clubbing. It may lead to end-stage renal disease (ESRD). The disease is also known as reflux nephropathy, interstitial nephritis, and chronic atrophic pyelonephritis. CP also includes rare variants like xanthogranulomatous pyelonephritis (XGP) and emphysematous pyelonephritis (EPN) [1]. The clinical presentation of CP is variable and non-specific. Some patients may be asymptomatic while others may present with malaise, fatigue, loss of appetite, loss of weight, cloudy urine, fever, backache, flank pain, or abdominal discomfort. In advanced stages of the disease, patients will have hypertension. XGP may be characterized by the presence of a unilateral palpable abdominal mass, while patients with EPN may present with signs of sepsis.

Chronic pyelonephritis may follow inadequate treatment or recurrence of acute pyelonephritis, composed of a localized immune response to bacteria that have been eradicated [2]. In children, the chief cause of CP is vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs) associated with renal scarring [3] [4]. In adults, renal scarring is rarely due to urinary tract infections [5] [6].

Xanthogranulomatous pyelonephritis (XGP) is a rare variant of CP and may be associated with longstanding obstructive urinary tract disorders and Proteus infection [7].

Emphysematous pyelonephritis (EPN) is another rare, potentially life-threatening variant of CP. The disease develops secondary to renal parenchymal infection with E.coli, Klebsiella, or Proteus species. It is characterized by a sudden onset of acute necrotizing pyelonephritis and the presence of a renal parenchymal gas, usually in poorly controlled diabetics [8].

Chills
  • Clinical features: Fever (usually high fever with chills and rigors). Dysuria. Hematuria. Pain in the costovertibral angle on the affected side. Presence of pus cell casts in urine analysis will show renal involvement.[hubpages.com]
  • High fever and shaking chills also may be signs that your kidney infection has spread to your bloodstream and can travel to others parts of your body.[drugs.com]
  • Symptoms of acute pyelonephritis typically include fever and chills, burning or frequent urination, aching pain on one or both sides of the lower back or abdomen, cloudy or bloody urine, and fatigue.[encyclopedia.com]
  • […] 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 or chills[healthline.com]
  • In addition to the clinical data, such as fever, chills and general malaise, the search for biomarkers that differentiate between patients with pyelonephritis and those with low UTI has been proposed.[elsevier.es]
Right Flank Pain
  • CASE: A 45 year-old female presents with a two day history of dysuria, fevers, suprapubic discomfort, and right flank pain. She tells you that her symptoms are similar to a prior urinary tract infection (UTI) with the exception of the fever.[emdocs.net]
Hypertension
  • Three patients with well documented unilateral chronic pyelonephritis (UCP) of bacterial origin, one hypertensive and two normo-tensive, were presented. Removal of the contracted kidney in the hypertensive patient did not eradicate the hypertension.[ncbi.nlm.nih.gov]
  • Severe renin-mediated hypertension was noted in 2 children as a result of selective renal damage from vesicoureteral reflux during the early years of life. In each case the reflux had been corrected successfully long before hypertension developed.[ncbi.nlm.nih.gov]
  • Chronic pyelonephritis secondary to vesicoureteral reflux has been shown to cause occasionally systemic hypertension.[ncbi.nlm.nih.gov]
  • Repeated urinary tract infections and hypertension are common events. Proteinuria is usually minimal and when present is associated with hypertension.[ncbi.nlm.nih.gov]
  • This operation can thus be recommended in selected cases of unilateral chronic pyelonephritis with hypertension.[ncbi.nlm.nih.gov]
Diastolic Hypertension
  • Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension. CONCLUSION: Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.[ncbi.nlm.nih.gov]
Diastolic Hypertension
  • Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension. CONCLUSION: Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.[ncbi.nlm.nih.gov]
Back Pain
  • Suggestive symptoms : kidney pain (back pain), micturition disorders with polyuria (urinating more) and nocturia (urinating at night) and occasional appearances of polaki-disuria, pain during urination, pyuria (urine with pus).[bendomd.com]
  • This 52-year-old white female complained of severe weakness and abdominal pain and, in addition, had suffered back pain for one month prior to admission.[pubs.rsna.org]
  • Epidural abscess : Be careful of patients with back pain and red flags such as IV drug use, recent instrumentation, immunosuppression, etc., with any flank pain or back pain and fever.[emdocs.net]
  • There is unilateral or bilateral loin pain, suprapubic pain or back pain. Fever is variable but can be high enough to produce rigors. Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.[patient.info]
Flank Pain
  • Some patients may be asymptomatic while others may present with malaise, fatigue, loss of appetite, loss of weight, cloudy urine, fever, backache, flank pain, or abdominal discomfort.[symptoma.com]
  • Chronic Pyelonephritis may come to attention during an episode of acute pyelonephritis with its attendant constitutional symptoms, flank pain, bacteruria, and pyuria.[pathwaymedicine.org]
  • In children, symptoms such as fever, lethargy, flank pain and nausea may be present.[lecturio.com]
  • Pyelonephritis Symptoms Acute pyelonephritis symptoms are systemic and the first indications would include high fever, flank pain, joint and muscle pains, headache and if severe, delirium might be present.[allhealthsite.com]
  • Symptoms may be absent or may include fever, malaise, and flank pain. Diagnosis is with urinalysis, culture, and imaging tests. Treatment is with antibiotics and correction of any structural disorders.[merckmanuals.com]
Dysuria
  • Dysuria. Hematuria. Pain in the costovertibral angle on the affected side. Presence of pus cell casts in urine analysis will show renal involvement. In lower urinary tract involvement there is only pus cells, no casts.[hubpages.com]
  • CLINICAL FEATURES May present with fever, flank pain Usually present with chronic renal failure or symptoms of hypertension frequency of micturition & dysuria 13.[slideshare.net]
  • 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]
  • Other symptoms of pyelonephritis would include: Dysuria Polyuria Nocturia Hematuria or pyuria Foul-smelling urine Renal colic (if due to presence of stones) Uncontrollable shivering Nausea and vomiting Diarrhea Hypotension (if sepsis has occurred) Poor[allhealthsite.com]
  • The authors found dysuria to have a likelihood ratio (LR) of 1.3, frequency to have a LR of 1.10, hematuria a LR of 1.72, nocturia a LR of 1.30, and urgency a LR of 1.22.[emdocs.net]
Nocturia
  • Suggestive symptoms : kidney pain (back pain), micturition disorders with polyuria (urinating more) and nocturia (urinating at night) and occasional appearances of polaki-disuria, pain during urination, pyuria (urine with pus).[bendomd.com]
  • Other symptoms of pyelonephritis would include: Dysuria Polyuria Nocturia Hematuria or pyuria Foul-smelling urine Renal colic (if due to presence of stones) Uncontrollable shivering Nausea and vomiting Diarrhea Hypotension (if sepsis has occurred) Poor[allhealthsite.com]
  • […] needle biopsy針生検 neobladder 新膀胱 nephrectomy腎摘出[術]、腎摘、腎切除[術] nephritis腎炎 nephrolithiasis腎結石 nephrology腎臓病学 nephropathy腎症 nephrostomy 腎瘻造設術 nephrotic syndromeネフローゼ症候群 nephrotoxicity腎毒性 neurogenic神経[原]性の neurogenic bladder 神経因性膀胱 neuropathic bladder 神経因性膀胱 nocturia[tokyo-med.ac.jp]
  • The authors found dysuria to have a likelihood ratio (LR) of 1.3, frequency to have a LR of 1.10, hematuria a LR of 1.72, nocturia a LR of 1.30, and urgency a LR of 1.22.[emdocs.net]
Cloudy Urine
  • Some patients may be asymptomatic while others may present with malaise, fatigue, loss of appetite, loss of weight, cloudy urine, fever, backache, flank pain, or abdominal discomfort.[symptoma.com]
  • 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]
Urinary Urgency
  • urgency Anorexia Some individuals do not show any symptoms of pyelonephritis at all.[allhealthsite.com]

Workup

The diagnosis of CP can be difficult due to its variable and often vague clinical presentation. It can be suspected in patients who provide a history of renal calculi, recurrent UTIs, acute pyelonephritis or VUR. Occasionally the diagnosis is suspected based on incidental radiological findings or in patients presenting with hypertension. Laboratory tests like a complete blood count may reveal normochromic, normocytic anemia with leukocytosis. C-reactive protein (CRP) may be elevated in severe CP [9]. Urinalysis is likely to show hematuria, proteinuria, leukocytes with occasional epithelial cells, and rarely WBC casts. The severity of renal dysfunction can be estimated by renal function tests like serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate [10]. Depending on the extent of renal damage there will be electrolyte imbalances like hyperkalemia, hyponatremia, and acidosis. Renal imaging is performed to detect the etiology of CP. Currently, magnetic resonance imaging (MRI) and computed tomography (CT) provide detailed information and are preferred over older modalities like plain X-rays, urography, and Tc-99m-DMSA nuclear scintigraphy, as well as histology [11]. In children, an ultrasound and a cystourethrogram are performed to exclude VUR [12].

Xanthogranulomatous pyelonephritis (XGP): Proteus, and less commonly Escherichia coli, Klebsiella, and Staphylococcus aureus, are found in urine cultures. Imaging studies like CT and MRI may detect a renal mass resembling a tumor [13]. However, the final diagnosis of XGP is based on histology of the nephrectomy specimen [13] [14].

Emphysematous pyelonephritis (EPN): Laboratory tests can show leukocytosis with elevated CRP [15], elevated blood glucose, and HbA1C levels. Blood and urine cultures may grow Escherichia coli, Klebsiella, or Proteus species. Gas may be noticed within the renal parenchyma on plain X-rays and ultrasound, while CT or MRI scans are useful in diagnosing the disease extent. [1] [16] [17] .

Nephrolithiasis
  • These abnormalities were not associated with overt obstruction or bacteriuria, but appeared to be more common in patients with recent onset and active recurrent nephrolithiasis.[ncbi.nlm.nih.gov]
  • Our observations indicate that autoimmune responses to THP may occur after exposure to THP by intravenous challenge in rabbits, by urinary reflux in pigs, and in recurrent nephrolithiasis in man.[ncbi.nlm.nih.gov]
  • The immune responses to Tamm-Horsfall protein in patients with recurrent nephrolithiasis were also examined, as were the antigenic similarities between Tamm-Horsfall protein and protein-containing components of uropathic bacteria.[ncbi.nlm.nih.gov]
  • Xanthogranulomatous Pyelonephritis This is an uncommon inflammatory state due to the constant obstruction in the kidneys because of nephrolithiasis (usually staghorn calculus) and would result to irreparable damage of the renal parenchyma.[allhealthsite.com]
  • Other Risk Factors: Diabetes mellitus, nephrolithiasis, chronic catheterization.[urology-textbook.com]
Small Kidney
  • Pathology of Chronic Pyelonephritis Small kidney with a nodular surface and cicatricial retractions Lost demarcation of cortex and medulla in affected areas of the kidney. Initial renal scars are frequently found at the poles.[urology-textbook.com]
  • Imaging : Renal ultrasound may show small kidneys with a thin cortex. Intravenous pyelogram (IVP) may show small kidneys, ureteric and caliceal dilatation/blunting with cortical scarring.[patient.info]
  • Back to the top of the page "Small kidneys#" Unfortunately it is still not uncommon for patients to present with chronic kidney failure and usually hypertension - when the kidneys are scanned they are small.[kidneypatientguide.org.uk]
  • We ought to note that while dilatations of the urinary tract are easy to detect in the prenatal period, it is common for small kidneys (renal hypoplasia) to go unnoticed in ultrasound examinations during pregnancy.[analesdepediatria.org]
Pyuria
  • Chronic Pyelonephritis may come to attention during an episode of acute pyelonephritis with its attendant constitutional symptoms, flank pain, bacteruria, and pyuria.[pathwaymedicine.org]
  • Suggestive symptoms : kidney pain (back pain), micturition disorders with polyuria (urinating more) and nocturia (urinating at night) and occasional appearances of polaki-disuria, pain during urination, pyuria (urine with pus).[bendomd.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]
  • Other symptoms of pyelonephritis would include: Dysuria Polyuria Nocturia Hematuria or pyuria Foul-smelling urine Renal colic (if due to presence of stones) Uncontrollable shivering Nausea and vomiting Diarrhea Hypotension (if sepsis has occurred) Poor[allhealthsite.com]
  • Pyelonephritis is a sporadic, subacute to chronic disorder and the diagnosis is based on urinary symptoms (pyuria, haematuria, bacteriuria).[agris.fao.org]
Abnormal Renal Function
  • Before birth, at 20 weeks of gestation, foetal urine already amounts to more than 90% of the total volume of amniotic fluid, so the finding of oligohydramnios past this gestational age is an excellent indicator of abnormal renal function in the foetus[analesdepediatria.org]
Ischemic Changes
  • Only type 2 glomeruli, which were considered to be ischemic changes, demonstrated granular and globular depositions of IgM and C3 in the collapsed and solidified shrunken tufts.[ncbi.nlm.nih.gov]

Treatment

  • The results of carindacillin treatment, as judged by bacteriological evaluation 1 month post-treatment, were good in 12 (32%) and moderate in 9 of the patients.[ncbi.nlm.nih.gov]
  • During the full-dose period of treatment netilmicin concentrations in serum were between 2 and 16 mg/l in serum and between 50 and 200 mg/l in urine.[ncbi.nlm.nih.gov]
  • They have found a decrease in these levels following treatment.[ncbi.nlm.nih.gov]
  • Urine samples were collected at the time of enrollment, 5-7 days after institution of antibiotic treatment, and 1.5 months after enrollment. Cytokine concentrations were measured by ELISA.[ncbi.nlm.nih.gov]
  • […] need urgent operational treatment.[infomeds.net]

Prognosis

  • Department of Radiology, University of Newcastle upon Tyne. t.h.j.goodship@ncl.ac.uk Abstract We studied the natural history, and therefore prognosis, of patients with chronic pyelonephritis presenting to adult nephrologists with a plasma or serum creatinine[ncbi.nlm.nih.gov]
  • The disease in most patients with unilateral disease runs a benign course; a poorer prognosis is associated with bilateral disease, hypertension and proteinuria.[ncbi.nlm.nih.gov]
  • Prognosis for chronic pyelonephritis Chronic pyelonephritis is diagnosed in 4 out of 1,000 asymptomatic adults. In children with urinary tract infections, prevalence of chronic pyelonephritis is as much as 40% to 50%.[ic.steadyhealth.com]
  • Prognosis of Kidney Infection Acute uncomplicated pyelonephritis has excellent prognosis and complete recovery is seen. Emphysematous pyelonephritis in diabetics shows very poor prognosis irrespective of the treatment.[lecturio.com]
  • Prognosis The Birmingham Reflux Study clearly showed that medical and surgical management are equally effective in preventing renal damage from VUR. [4] Almost all children should receive a trial of medical management.[emedicine.medscape.com]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • Renal imaging is performed to detect the etiology of CP.[symptoma.com]
  • In considering glomerular sclerosis, it is significant that loss of UEA-I binding and alpha 1AT deposition are common to both CPN and CDPGN, although their original etiologies are quite different.[ncbi.nlm.nih.gov]
  • Etiology of Chronic Pyelonephritis Relapsing Acute Pyelonephritis: Recurrent acute pyelonephritis in childhood results in renal scarring. New renal scars develop seldom after the age of 5 years, but are possible until puberty.[urology-textbook.com]
  • In the absence of etiological therapy (in the case of bilateral wrinkling) treatment is modern hypotensive means.[medicalency.com]

Epidemiology

  • Epidemiology of chronic pyelonephritis The proportion of chronic pyelonephritis as a cause of end-stage renal disease in children is up to 20%, but it has a declining tendency.[urology-textbook.com]
  • Epidemiology In the United States, VUR may be present in 30-40% of children with UTIs. The prevalence rate of VUR in siblings of patients with chronic pyelonephritis is approximately 35%.[emedicine.medscape.com]
  • Epidemiology of Kidney Infection Acute pyelonephritis is estimated at a prevalence of 15-17 cases per 10000 among females and 3-4 cases per 10000 among males in the population.[lecturio.com]
  • Empirical therapy with antibiotics should be prescribed based on epidemiological studies of the region. References [1] G. Montini, K. Tullus, I. Hewitt Febrile urinary tract infections in children [2] M.L. Herreros Fernández, N. González Merino, A.[elsevier.es]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology of Chronic Pyelonephritis Ask-Upmark Kidney: The Ask-Upmark kidney is a special form of chronic pyelonephritis with an activated renin-angiotensin-aldosterone system (RAAS).[urology-textbook.com]
  • Etiology and Pathophysiology Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage renal disease (ESRD).[emedicine.medscape.com]
  • Pathophysiology of Kidney Infection Acute Pyelonephritis Image : “Very high magnification micrograph of acute pyelonephritis. H&E stain. Kidney biopsy” by Nephron.[lecturio.com]

Prevention

  • To prevent the development of a severe syndrome, such as renal failure, treatment and prevention of diseases of the urinary system should be carried out on time, preventing the development of subsequent complications.[acikgunluk.net]
  • Bacteriae usually attack the lower parts of the tract, as urine leak prevents the spreading of infection by the tract.[healthy-inside.com]
  • U may require surgery to correct hydronephrosis & facilitate urinary drainage to prevent urinary stagnation which predispose to stones.[healthtap.com]
  • Treatment options usually include antibiotic medications to treat the infection and may involve surgery to correct an anatomical problem and prevent future infections, as well as other complications.[wisegeek.com]
  • Clinical immunological study on prevention and treatment of chronic pyelonephritis with yishenkang granule 益肾康防治慢性肾盂肾炎的临床免疫学研究 Both lymphocytes and plasma cells are seen at high magnification in this case of chronic pyelonephritis 慢性肾盂肾炎病人高倍镜下见淋巴细胞和浆细胞[eng.ichacha.net]

References

Article

  1. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160:797-805.
  2. Vachvanichsanong P. Urinary tract infection: one lingering effect of childhood kidney diseases - review of the literature. J Nephrol. 2007;20:21-28.
  3. Marra G, Oppezzo C, Ardissino G, et al. Severe vesicoureteral reflux and chronic renal failure: a condition peculiar to male gender? Data from the ItalKid Project. J Pediatr. 2004;144:677-681
  4. Wennerstrom M, Hansson S, Jodal U, et al. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr. 2000;136:30-34.
  5. Moreau JF, Grenier P, Grunfeld JP, et al. Renal clubbing and scarring in adults: a retrospective study of 110 cases. Urol Radiol. 1979-1980;1:129-136
  6. Guignard JP. Importance of vesicoureteral reflux in the pathogenesis of chronic pyelonephritis [in French]. Schweiz Med Wochenschr. 1983;113:223-228
  7. Grainger RG, Longstaff AJ, Parsons MA. Xanthogranulomatous pyelonephritis: a reappraisal. Lancet. 1982;1:1398-1401
  8. Rubenstein JN, Schaeffer AJ. Managing complicated urinary tract infections: the urologic view. Infect Dis Clin North Am. 2003;17:333-351.
  9. Yang WJ, Cho IR, Seong-do H, et al. Clinical implication of serum C-reactive protein in patients with uncomplicated acute pyelonephritis as marker of prolonged hospitalization and recurrence. Urology. 2009;73:19-22.
  10. Stevens LA, Coresh J, Feldman HI, et al. Evaluation of the modification of diet in renal disease study equation in a large diverse population. J Am Soc Nephrol. 2007;18:2749-2757.
  11. Kljucevsek D, Kljucevsek T, Kersnik LT, et al. Catheter-free methods for vesicoureteric reflux detection: our experience and a critical appraisal of existing data. Pediatr Nephrol. 2010;25:1201-1206.
  12. Riccabona M, Fotter R. Urinary tract infection in infants and children: an update with special regard to the changing role of reflux. Eur Radiol. 2004; 14: L78-L88.
  13. Loffroy R, Guiu B, Wafta J, et al. Xanthogranulomatous pyelonephritis in adults: clinical and radiological findings in diffuse and focal forms. Clin Radiol. 2007;62:884-890.
  14. Dwivedi US, Goyal NK, Saxena V, et al. Xanthogranulomatous pyelonephritis: our experience with review of published reports. ANZ J Surg. 2006;76:1007-1009
  15. Kondo T, Okuda H, Suzuki M, et al. A case of emphysematous pyelonephritis improved with conservative therapy - indication for conservative therapy. Hinyokika Kiyo. 2000;46:335-338.
  16. Evanoff GV, Thompson CS, Foley R, et al. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83:149-154.
  17. Vourganti S, Agarwal PK, Bodner DR, et al. Ultrasonographic evaluation of renal infections. Radiol Clin North Am. 2006;44:763-775

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Last updated: 2019-07-11 20:47