Acute Pyelonephritis is inflammation of renal parenchyma and the collecting system.

1. Acute Pyelonephritis and Chronic Pyelonephritis

2. Urinary tract infection
• Commonly involves lower urinary tract .
• Occurs more commonly in female
• Two types;
1. Complicated UTI
2. Uncomplicated UTI
• Complicated UTI is defined as an episodes of infection with an increased risk of serious
complication or treatment failure.
• Uncomplicated UTI is episodes of infection with less risk of serious complication

3. • Pyelonephritis is defined as inflammation affecting the
tubules,interstitium and renal pelvis.
Two forms - Acute pyelonephritis
-Chronic pyelonephritis
Acute pyelonephritis;
It is a suppurative inflammation of the kidney caused by bacterial
infection.

4. Etiology and Pathogenesis
• More than 85% of cases of UTI are caused by the gram negative bacilli that are normal
inhabitant of intestinal tract.
• Most common organism involved are E. Coli, Proteus, klebsiella, and Enterobacter.
• Routes of infection;
1.Hematogenous route( primary site in the tonsils, teeth caries , boils,carbuncle)
2.Ascending infection ( urinary stasis in presence of calculi)

5. Pathogenesis;
• Colonization by coliform bacteria of distal urethra and introitus(In Female)
• From urethra to the bladder during urethral catheterization or other
instrumentation.
• From bladder to kidney;
• Urinary tract obstruction and stasis of urine.
• Vesico-ureteral reflux (incompetence of vesicoureteral valve)
• Intrarenal reflux

6. Clinical feature
• More common in females especially during childhood,
• At puberty after intercourse and during pregnancy.
• Symptoms;
• Fever with chills and rigors
• Flank pain, Nausea and vomiting
• Cystitis symptom may or may not be present
Sign;
• Costovertebral angle tenderness
• Flank fullness
• Symptoms may vary from a mild illness to a severe illness with septic shock, renal failure and
threat to life

7. Investigation;
• Blood – Hb%, CBC ( leukocytosis), Differential count
• Urine – Routine and microscopic examination, culture and sensitivity
Pyuria is almost always present.
• RFT- Serum Creatinine, Serum Urea

8. • USG Abdomen and pelvis- To rule out pyonephrosis , Perirenal
abscess, and obstruction of collecting system by renal calculi .
• CECT- Typically shows decreased opacification of affected
Parenchyma, typically in patchy, wedge shaped or linear distribution

9. Management;
• Plenty of fluid intake
• Antipyretic and Analgesic can be given for fever and lower abdominal pain
• Antibiotic are recommended in all case of proven UTI
• If urine culture has been performed treatment may be started while awaiting the result.
• Initially broad spectrum antibiotic coverage using Cefalexin , Ciprofloxacin can be used.
• Later Antibiotic can be switched according to culture and sensitivity report.
.

10. Acute Pyelonephritis in children
• In the age group <3 month, it is more common in boys.
• In the age group >1 year , it is more common in girls.
Underlying causes are;
• Urinary stasis due to Vesico-ureter reflux,
• detrusor-sphincter dyssynergia ,
• poor bladder emptying habit
• Outlet obstruction ,
• Neurological disorder secondary to spina bifida
.

11. It causes renal scarring secondary to renal parenchyma inflammation.
• Scarring can be detected on IVU,DMSA (dimercaptosuccinic acid) scan.
• 10-20% of children with renal scarring will develop hypertension.
• VUR Graded as;
Grade1: reflux into ureter
•
Grade 2:Reflux into ureter and renal pelvis
•
Grade 3: Reflux assosciated with moderate dilatation on an IVU
•
Grade 4:Additional blunting of Fornices
•
Grade 5:Absent Papillary impressions

12. • VUR is confirmed by micturating Cystogram
• Grade 1-3 generally resolves spontaneously.
• Ureteric re-implantation, peri-ureteric injection of Teflon should be considered
if episode of acute pyelonephritis recur despite antibiotic therapy.

13. Pyelonephritis complicating pregnancy
• It is most often presents between 20 and 28 week of gestation.
• Pyelonephritis is more common in pregnant women with underlying urological
abnormality or diabetes.
• Malaise, fever,loin pain and rigors are major complaints.
• Pyonephrosis and perirenal abscess are rare complication but should be
suspected when treatment fails.

14. Emphysematous Pyelonephritis
• Emphysematous pyelonephritis is a fulminant , necrotising,life-threatening . variant of acute
Pyelonephritis.
• Caused by E.coli, Klebsiella pneumonia , Pseudomonas aeruginosa and Proteus Mirabilis.
•
• Upto 90% cases occur in diabetic patients and urinary tract obstruction may be present.

15. • Symptoms are similar of acute pyelonephritis, and there may be loin
mass.
• Gas can be detected on a plain film, on USG,
and CT scan.
• IV broad spectrum antibiotic and percutaneous catheter drainage .
• Nephrectomy may be needed in most severely ill patient

16. Chronic Pyelonephritis
Chronic Pyelonephritis is a disorder in which chronic tubulointerstitial
inflammation and scarring involve the calyces and pelvis.
It remains an important cause of kidney destruction in children with severe lower
urinary tract abnormalities.
Two form;
• Reflux Nephropathy
• Chronic obstructive Pyelonephritis

17. Clinical feature
• Gradual onset or present with acute recurrent pyelonephritis such as loin pain,
fever, pyuria and bacteriuria
• Reflux nephropathy causes hypertension in children .
• Imaging studies shows asymmetrically contracted kidneys with coarse scars,
blunting and deformity of calyceal system.

18. Investigation;
• Complete blood profile
• Urinalysis results may reveal pyuria.
• Urine culture isolates gram negative bacteria- E. coli,or Proteus species
• Serum Creatinine and Blood urea nitrogen level.
• IVU- calceal dilatation and blunting with cortical scars.
• Voiding cystourethrogram- reflux of urine to renal pelvis and ureteral dilatation
• DMSA Scan-detect renal scars

19. Management;
Goal of management are
1.Prevent recurrent febrile Urinary tract infection.
2.Prevent Renal injury
3.Minimize Morbidity of treatment and follow up
Preventive strategies -prophylactic antibiotic.
Medical care- Antibiotic , fluid and electrolyte management
Surgical care- Ureteral Re-implantation

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