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| {{DiseaseDisorder infobox | | | __NOTOC__ |
| Name = Pyelonephritis |
| | {| class="infobox" style="float:right;" |
| ICD10 = {{ICD10|N|10||n|10}}-{{ICD10|N|12||n|10}}, {{ICD10|N|20|9|n|20}} |
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| ICD9 = {{ICD9|590}}, {{ICD9|592.9}} |
| | | [[File:Siren.gif|link=Urinary tract infection resident survival guide|41x41px]]|| <br> || <br> |
| ICDO = |
| | | [[Urinary tract infection resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| Image = Acute pyelonephritis.jpg|
| | |} |
| Caption = Acute Pyelonephritis: Gross, multiple cortical abscesses seen from the external surface (an excellent example) <br> <small> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small>|
| | {{Pyelonephritis}} |
| OMIM = |
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| OMIM_mult = |
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| MedlinePlus = 000522 |
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| DiseasesDB = 29255 |
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| DiseasesDB_mult = {{DiseasesDB2|11052}} |
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| MeshID = D011704 |
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| }}
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| {{SI}} | |
| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}} | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{Editor Join}} | | {{CMG}}; {{AE}} {{CZ}}, {{USAMA}} {{SSH}} |
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| ==Overview==
| | {{SK}} Kidney infection; acute pyelonephritis; acute kidney infection; chronic pyelonephritis; necrotizing pyelonephritis; acute necrotizing pyelonephritis |
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| '''Pyelonephritis''' is an ascending [[urinary tract infection]] that has reached the ''pyelum'' ([[Renal pelvis|pelvis]]) of the [[kidney]] (''nephros'' in [[Greek language|Greek]]). If the infection is severe, the term "'''urosepsis'''" is used interchangeably ([[sepsis]] being a [[systemic inflammatory response syndrome]] due to infection). It requires [[antibiotic]]s as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of [[nephritis]]. It can also be called ''pyelitis''.<ref name=Ramakrishnan>{{cite journal | author=Ramakrishnan K, Scheid DC | title=Diagnosis and management of acute pyelonephritis in adults | journal=Am Fam Physician | year=2005 | pages=933-42 | volume=71 | issue=5 | id=PMID 15768623 | url=http://www.aafp.org/afp/20050301/933.html}}</ref>. There are four different types of pyelonephritis:
| | ==[[Pyelonephritis overview|Overview]]== |
| | ==[[Pyelonephritis Historical perspective|Historical Perspective]]== |
| | ==[[Pyelonephritis classification|Classification]]== |
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| * '''Acute Pyelonephritis'''
| | ==[[Pyelonephritis pathophysiology|Pathophysiology]]== |
| :*Acute pyelonephritis is a common clinical diagnosis in patients who present with fever, chills, and flank tenderness.
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| :*Infections typically result from ascending retrograde spread through the collecting ducts into the renal parenchyma.
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| :*Patients are referred for CT evaluation of acute pyelonephritis when symptoms are poorly localized or complications are suspected.
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| * '''Chronic Pyelonephritis'''
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| :*Chronic pyelonephritis is a somewhat controversial disease from a pathogenetic standpoint. It is unclear that, whether it is an active chronic infection, arises from multiple recurrent infections, or represents stable changes from a remote single infection.
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| :*[[Hypertension]] is frequently a long-term sequela.
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| * '''Emphysematous Pyelonephritis'''
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| :* Emphysematous pyelonephritis represents a severe life-threatening infection (overall mortality rate of approximately 50%) of the renal parenchyma with gas-forming bacteria.
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| :* Underlying poorly controlled [[diabetes mellitus]] is present in up to 90% of patients who develop emphysematous pyelonephritis.
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| :* Patients present clinically with varying degrees of renal failure, lethargy, acid-base irregularities, and hyperglycemia.
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| :* E coli is the causative bacterial source in approximately 70% of cases
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| * '''Xanthogranulomatous Pyelonephritis'''
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| :*Xanthogranulomatous pyelonephritis (XGP) is a rare inflammatory condition usually secondary to chronic obstruction caused by [[nephrolithiasis]] and resulting in infection and irreversible destruction of the renal parenchyma.
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| :*XGP is associated with a staghorn calculus in approximately 70% of cases.
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| :*Patients with diabetes are particularly predisposed to the formation of XGP.
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| :*Treatment is nephrectomy.
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| :*At histologic analysis, the inflammatory mass is composed of lipid-laden macrophages and chronic inflammatory cells.
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| ==Signs and symptoms== | | ==[[Pyelonephritis causes|Causes]]== |
| It presents with [[dysuria]] (painful voiding of urine), [[abdominal pain]] (radiating to the back on the affected side) and tenderness of the bladder area and the side of the involved kidney ("renal angle tenderness"). In many cases there are systemic symptoms in the form of [[fever]], [[Rigor (medicine)|rigors]] (violent shivering while the termpature rises), [[headache]] and [[vomiting]]. In severe cases, [[delirium]] may be present.<ref name=Ramakrishnan/>
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| ==Diagnosis== | | ==[[Pyelonephritis differential diagnosis|Differentiating Pyelonephritis from other Diseases]]== |
| The presence of [[nitrite]] and [[leukocyte]]s (white blood cells) on a urine dipstick test in patients with typical symptoms are sufficient for the diagnosis of pyelonephritis, and are an indication for empirical treatment. Formal diagnosis is with [[microbiological culture|culture]] of the urine; [[blood culture]]s may be needed if the source of the infection is initially doubtful.<ref name=Ramakrishnan/>
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| If a [[kidney stone]] is suspected (e.g. on the basis of characteristic [[Renal colic|colicky pain]], disproportionate amount of blood in the urine), [[X-ray]]s of the kidneys, [[ureter]]s and [[Urinary bladder|bladder]] (KUB) may assist in identifying radioopaque stones.<ref name=Ramakrishnan/>
| | ==[[Pyelonephritis epidemiology and demographics|Epidemiology and Demographics]]== |
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| In patients with recurrent ascending urinary tract infections, it may be necessary to exclude an anatomical abnormality, such as vesicoureteral reflux (urine from the bladder flowing back into the [[ureter]]) or [[polycystic kidney disease]]. Investigations that are commonly used in this setting are [[medical ultrasonography|ultrasound]] of the kidneys or [[voiding cystourethrogram|voiding cystourethrography]].<ref name=Ramakrishnan/>
| | == [[Pyelonephritis risk factors|Risk Factors]] == |
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| ===Acute Pyelonephritis=== | | == [[Pyelonephritis Screening|Screening]] == |
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| ====Contrast Nephrograms==== | | ==[[Pyelonephritis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| *Acute pyelonephritis consist of focal areas of striated or wedge-shaped hypoperfusion, resulting in a characteristic '''striated nephrogram'''.
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| *Striations result from stasis of contrast material within edematous tubules that demonstrates increasing attenuation over time.
| | [[Pyelonephritis diagnostic study of choice|Diagnostic study of choice]] |[[Pyelonephritis history and symptoms| History and Symptoms]] | [[Pyelonephritis physical examination|Physical Examination]] | [[Pyelonephritis laboratory findings|Laboratory Findings]] | [[Pyelonephritis electrocardiogram|Electrocardiogram]] | [[Pyelonephritis x ray|X Ray Findings]] | [[Pyelonephritis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Pyelonephritis CT scan|CT-Scan Findings]] | [[Pyelonephritis MRI|MRI Findings]] | [[Pyelonephritis other imaging findings|Other Imaging Findings]] | [[Pyelonephritis other diagnostic studies|Other Diagnostic Studies]] |
| *The infected kidney is usually enlarged, and there is often stranding in the perinephric fat.
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| *Delayed views of the infected kidney may demonstrate a nephrogram with increased attenuation.
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| ====Computed Tomography====
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| [http://www.radswiki.net Images courtesy of RadsWiki] | |
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| <gallery>
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| Image:Acute pyelonephritis 001.jpg|CT: Acute pyelonephritis
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| Image:Acute pyelonephritis 002.jpg|CT: Acute pyelonephritis
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| Image:Acute pyelonephritis 003.jpg|CT: Acute pyelonephritis
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| </gallery>
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| ===Chronic Pyelonephritis===
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| ====Computed Tomography====
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| Imaging findings are characterized by renal scarring, atrophy and cortical thinning, hypertrophy of residual normal tissue, caliceal clubbing secondary to retraction of the papilla from overlying scar, thickening and dilatation of the caliceal system, and overall renal asymmetry.
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Chronic-pyelonephritis-001.jpg|CT image demonstrates chronic pyelonephritis on the right
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| Image:Chronic-pyelonephritis-002.jpg|CT image demonstrates chronic pyelonephritis on the right
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| Image:Chronic-pyelonephritis-003.jpg|CT image demonstrates chronic pyelonephritis on the right
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| </gallery>
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| ===Emphysematous Pyelonephritis===
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| ====Plain film====
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| *Conventional radiography may demonstrate gas bubbles overlying the renal fossa or may show a diffusely mottled kidney with radially oriented gas corresponding to the renal pyramids.
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| ====Ultrasonography====
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| *US will characteristically show an enlarged kidney containing high-amplitude echoes within the renal parenchyma, often with low-level posterior dirty acoustic shadowing; however, the depth of parenchymal involvement may be underestimated at US, and multiple renal stones may also manifest as echogenic foci without "clean" posterior shadowing.
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| ====Computed Tomography====
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| *Additional evaluation with CT will confirm the presence and extent of parenchymal gas and will often allow identification of the source of obstruction when present.
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| *The use of intravenous contrast material will often reveal asymmetric renal enhancement or delayed excretion, and, during the nephrographic phase, will help identify areas of focal tissue necrosis or abscess formation.
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Emphysematous-pyelonephritis-001.jpg|CT: Emphysematous pyelonephritis
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| Image:Emphysematous-pyelonephritis-002.jpg|CT: Emphysematous pyelonephritis
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| Image:Emphysematous-pyelonephritis-003.jpg|CT: Emphysematous pyelonephritis
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| </gallery>
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| ===Xanthogranulomatous Pyelonephritis===
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| ====Urography====
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| Classic urographic triad in diffuse xanthogranulomatous pyelonephritis consists of unilaterally decreased or (more commonly) absent renal excretion, a staghorn calculus, and a poorly defined mass or diffuse renal enlargement.
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| ====Ultrasonography====
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| At sonography, the inflammatory mass itself is hypoechoic, with central echogenic foci corresponding to renal calculi.
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| ====Computed Tomography====
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| The CT findings of xanthogranulomatous pyelonephritis are pathognomonic in most cases: diffuse reniform enlargement with ill-defined central low attenuation, apparent cortical thinning, and central calculi.
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| **Extension into the perinephric space and beyond the Gerota fascia is not uncommon.
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| **Central areas of low attenuation represent nonenhancing xanthomatous material that may demonstrate attenuation values less than those of water.
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Xanthogranulomatous pyelonephritis 001.jpg|CT image demonstrates right xanthogranulomatous pyelonephritis
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| Image:Xanthogranulomatous pyelonephritis 002.jpg|CT image demonstrates right xanthogranulomatous pyelonephritis
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| Image:Xanthogranulomatous pyelonephritis 003.jpg|CT image demonstrates right xanthogranulomatous pyelonephritis
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| </gallery>
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| ==Causes==
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| Most cases of "community-acquired" pyelonephritis are due to bowel organisms that enter the urinary tract. Common organisms are ''[[Escherichia coli|E. coli]]'' (70-80%) and ''[[Enterococcus faecalis]]''. Hospital-acquired infections may be due to coliforms and enterococci, as well as other organisms uncommon in the community (e.g. [[Klebsiella]] spp., ''[[Pseudomonas aeruginosa]]''). Most cases of pyelonephritis start off as lower urinary tract infections, mainly [[cystitis]] and [[prostatitis]].<ref name=Ramakrishnan/>
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| Risk is increased in the following situations:<ref name=Ramakrishnan/><ref>{{cite journal |author=Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE |title=Risk factors associated with acute pyelonephritis in healthy women |journal=Ann. Intern. Med. |volume=142 |issue=1 |pages=20-7 |year=2005 |pmid=15630106 |doi=}}</ref>
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| * Mechanical: any structural abnormalities to the kidneys and the urinary tract, [[Kidney stone|calculi]] (kidney stones), [[Urinary catheterization|urinary tract catheterisation]], urinary tract stents or drainage procedures (e.g. [[nephrostomy]]), [[pregnancy]], neuropathic bladder (e.g. due to spinal cord damage, [[spina bifida]] or [[multiple sclerosis]]) and [[prostate]] disease (e.g. [[benign prostatic hyperplasia]]) in men
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| * Constitutional: [[diabetes mellitus]], [[immunocompromised]] states
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| * Behavioural: change in sexual partner within the last year, [[spermicide]] use
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| * Positive family history (close family members with frequent urinary tract infections)
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| ==Pathology==
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| Acute pyelonephritis is an ''exudative purulent localized inflammation'' of the renal pelvis (collecting system) and kidney. The renal 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, glomeruli and vessels are normal.[http://www.pathologyatlas.ro/Interstitial%20Pyelonephritis1.html] Gross pathology often reveals pathognomonic radiations of [[hemorrhage]] and suppuration through the [[renal pelvis]] to the [[renal cortex]]. Chronic infections can result in [[fibrosis]] and scarring.
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| ===Acute pyelonephritis===
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| <youtube v=aZ2il9a63J4/>
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| ===Chronic pyelonephritis===
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| <youtube v=Q62z5EfzQjE/>
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| ==Treatment== | | ==Treatment== |
| | [[Pyelonephritis medical therapy|Medical Therapy]] | [[Pyelonephritis interventions|Interventions]] | [[Pyelonephritis surgery|Surgery]] | [[Pyelonephritis primary prevention|Primary Prevention]] | [[Pyelonephritis secondary prevention|Secondary Prevention]] | [[Pyelonephritis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Pyelonephritis future or investigational therapies|Future or Investigational Therapies]] |
| | ==Case Studies== |
| | [[Pyelonephritis case study one|Case #1]] |
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| As practically all cases of pyelonephritis are due to bacterial infections, [[antibiotic]]s are the mainstay of treatment. Mild cases may be treated with oral therapy, but generally [[intravenous]] antibiotics are required for the initial stages of treatment. The type of antibiotic depends on local practice, and may include [[fluoroquinolone]]s (e.g. [[ciprofloxacin]]), [[beta-lactam antibiotic]]s (e.g. [[amoxicillin]] or a [[cephalosporin]]), [[trimethoprim]] (or [[co-trimoxazole]]) or [[nitrofurantoin]]. [[Aminoglycoside]]s are avoided due to their toxicity, but may be added for a short duration.<ref name=Ramakrishnan/>
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| If the patient is unwell and septic, [[intravenous fluid]]s may be administered to compensate for the reduced oral intake, insensible losses (due to the raised temperature) and [[vasodilation]] and to maximise urine output.
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| In recurrent infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to improve chances of recurrence. If no abnormality is identified, some studies suggest long-term [[prophylaxis|preventative]] (prophylactic) treatment with antibiotics, either daily or after [[sexual intercourse]].<ref>{{cite journal |author=Schooff M, Hill K |title=Antibiotics for recurrent urinary tract infections |journal=American family physician |volume=71 |issue=7 |pages=1301-2 |year=2005 |pmid=15832532 |doi=}}</ref> In children at risk of recurrent UTIs, the evidence is inconclusive as to whether long-term prophylactic antibiotics are of use.<ref>{{cite journal |author=Williams GJ, Wei L, Lee A, Craig JC |title=Long-term antibiotics for preventing recurrent urinary tract infection in children |journal=Cochrane database of systematic reviews (Online) |volume=3 |issue= |pages=CD001534 |year=2006 |pmid=16855971 |doi=10.1002/14651858.CD001534.pub2}}</ref> Ingestion of cranberry juice has been studied as a prophylactic measure; while studies are heterogeneous, many suggest a benefit.<ref>{{cite journal |author=Raz R, Chazan B, Dan M |title=Cranberry juice and urinary tract infection |journal=Clin. Infect. Dis. |volume=38 |issue=10 |pages=1413-9 |year=2004 |pmid=15156480 |doi=10.1086/386328}}</ref>
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| ==Epidemiology==
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| Pyelonephritis is very common, with 12-13 [[incidence|cases annually]] per 10,000 population in women and 3-4 cases per 10,000 in men. Young women are most likely to be affected, traditionally reflecting [[Human sexual behavior|sexual activity]] in that age group. Infants and the elderly are also at increased risk, reflecting anatomical abnormalities and hormonal status.<ref>{{cite journal |author=Czaja CA, Scholes D, Hooton TM, Stamm WE |title=Population-based epidemiologic analysis of acute pyelonephritis |journal=Clin. Infect. Dis. |volume=45 |issue=3 |pages=273-80 |year=2007 |pmid=17599303 |doi=10.1086/519268}}</ref>
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| == See also ==
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| * [[Pyonephrosis]]
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| == References ==
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| {{reflist|2}}
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| == External links ==
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| * {{GPnotebook|523567119}}
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| *[http://www.patient.co.uk/showdoc/40024643 Patient UK]
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| *[http://kidney.niddk.nih.gov/kudiseases/pubs/pyelonephritis/index.htm NKUDIC]
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| *[http://goldminer.arrs.org/search.php?query=Xanthogranulomatous%20pyelonephritis Goldminer: Xanthogranulomatous pyelonephritis]
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| *[http://goldminer.arrs.org/search.php?query=Chronic%20pyelonephritis Goldminer: Chronic pyelonephritis]
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| *[http://goldminer.arrs.org/search.php?query=emphysematous%20pyelonephritis Goldminer: Emphysematous pyelonephritis]
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| *[http://goldminer.arrs.org/search.php?query=pyelonephritis Goldminer: Pyelonephritis]
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| ==Additional Resources==
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| {{refbegin|2}} | |
| * Bhatt, Shweta, MacLennan, Gregory, Dogra, Vikram. [http://www.ajronline.org/cgi/content/abstract/188/5/1380 Renal Pseudotumors.] Am. J. Roentgenol. 2007 188: 1380-1387.
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| *Perry J. Pickhardt, Gael J. Lonergan, Charles J. Davis, Jr, Naoko Kashitani, and Brent J. Wagner. [http://radiographics.rsnajnls.org/cgi/content/abstract/20/1/215 From the Archives of the AFIP : Infiltrative Renal Lesions: Radiologic-Pathologic Correlation.] RadioGraphics 2000 20: 215-243.
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| *William D. Craig, Brent J. Wagner, and Mark D. Travis. [http://radiographics.rsnajnls.org/cgi/content/abstract/28/1/255 From the Archives of the AFIP: Pyelonephritis: Radiologic-Pathologic Review.] RadioGraphics 2008 28: 255-276.
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| *David E. Grayson, Robert M. Abbott, Angela D. Levy, and Paul M. Sherman. [http://radiographics.rsnajnls.org/cgi/content/abstract/22/3/543 Emphysematous Infections of the Abdomen and Pelvis: A Pictorial Review.] RadioGraphics 2002 22: 543-561.
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| *Bruce A. Urban, and Elliot K. Fishman. [http://radiographics.rsnajnls.org/cgi/content/abstract/20/3/725 Tailored Helical CT Evaluation of Acute Abdomen.] RadioGraphics 2000 20: 725-749.
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| {{refend}}
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| {{Nephrology}}
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| {{SIB}}
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| | [[Category:Medicine]] |
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| [[fr:Pyélonéphrite]]
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| [[ja:腎盂腎炎]]
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