RENAL ABSCESS

INTRODUCTION
Abscesses of the kidney account for 0.2% of all intra-abdominal abscesses. Peri-nephric
abscesses are collections of pus between the renal capsule and Gerota’s fascia; they account for 0.02%
of all abdominal abscesses. These abscesses have a poorer prognosis and are more difficult to
treat than intrarenal abscess. Intra-renal abscess or a "Renal carbuncle", is encapsulated
necrotic material within the renal parenchyma which now includes focal bacterial
nephritis, acute multifocal bacterial Staphylococcus aureus. It is now superseded by E. coli,
infections via urinary tract.
PERINEPHRIC ABSCESS
An abscess of the perinephric fat that abuts the renal cortex can arise as a complication
either a pre-existing pyelonephritis (majority) or from hematogenous seeding.
PERINEPHRIC vs RENAL ABSCESS
Perinephric Renal
Necrotic Area perinephric fat between the renal parenchyma
renal cortex and Gerota's fascia
Cause Pyelonephritis(Majority) Pyelonephritis( Vast Majority)
Risk of morbidity
Higher Lower
REVIW OF ANATOMY AND PHYSIOLOGY OF KIDNEY
Location of the Kidneys
 There are two kidneys which lie retroperioneally in the lumbar area.
 The right kidney is lower than the left due to displacement by the liver.
 Connective tissue anchors the kidneys to surrounding structures and helps maintain their
normal position.
 Each kidney is bean shaped and measures approximately 11cm x 6cm x 3cm and weighs
120 – 170 grams.
 The kidneys are enclosed by a fibrous capsule and the parenchyma consists of a cortex
and a medulla.
 Within the medulla approximately 8–18 triangular structures called renal pyramids are
found, and at the base of these pyramids renal papillae are directed towards the centre of
the kidney.

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  Together the cortex and the renal pyramids constitute the parenchyma of the kidney and
structurally the parenchyma of each kidney consists of approximately 1 million nephrons
which are the functional units of the kidney.

Renal Blood
Supply
 The kidneys receive their blood supply from the renal arteries which branch to the left
and right from the abdominal aorta.
 This blood supply to the kidney is equal to 21% of cardiac output and 99% of this cardiac
output returns to the general body circulation via the renal vein.
 The remaining 1% undergoes further processing in the nephron resulting in urine.
The Nephron
 The function unit of the kidney is the nephron and each nephron contains two
components:
 Glomerulus and Bowmans capsule (Renal Corpuscle).
 Tubular Component
 The Glomerulus and Bowmans Capsule allows blood to be filtered.
 This is followed by the proximal convoluted tubule which can absorb the bulk of the
filtrate.

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  The next segment is the Loop of Henley which is divided into the Descending and
Ascending Limb.
 The remainder of the nephron consists of a Distal Convoluted which drains into the
Collecting Ducts

 The kidneys perform the essential function of removing waste products from the blood
and regulating the water fluid levels. The diagram above shows the basic structure of the
kidney.
 Each nephron of the kidney contains blood vessels and a special tubule. As the filtrate
flows through the tubule of the nephron, it becomes increasingly concentrated into urine.
 Waste products are transferred from the blood into the filtrate, while nutrients are
absorbed from the filtrate into the blood.
Filtration
 The first step in the production of urine is called glomerular filtration which is the forcing
of fluids and dissolved substances through a porous membrane by pressure.
 When blood enters the glomerulus the blood pressure in the glomerulus forces water and
dissolved substances through the membrane.
 The resulting fluids is called filtrate however this amount also depends on opposing
forces in the Bowmans capsule and the glomerulus.
Functions of the Kidney
 Maintains fluid balance
 Maintains electrolyte balance
 Controls acid base balance
 Removes wastes and toxins
 Activates vitamin d produces rennin (renin is a protein (enzyme) released by special
kidney cells when you have decreased salt (sodium levels) or low blood volume, renin
also plays a role in the release of aldosterone, a hormone that helps control the body's salt
and water balance)
 Produces erythropoietin. ( a hormone produced by the kidney that promotes the formation
of red blood cells in the bone marrow.

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DEFINITION OF RENAL ABSCESS
Renal abscess is a collection of pus around kidney. Pus is formed following infection of
soft tissue around kidney or infection of peripheral kidney tissue. Renal abscess is and
uncommon disease caused by trauma and infection associated with kidney stone.
A pus-filled area that develops in the kidney as a result of inflammation. A renal abscess
is caused either by bacteria from an infection traveling to the kidneys through the bloodstream or
by a urinary tract infection traveling to the kidney and then spreading to the kidney tissue.

RISK FACTORS
 Inadequately treated or delayed treatment of UTI or pyelonephritis
 Diabetes mellitus
 Renal calculi
 Ureteral obstruction
 Any underlying urinary tract abnormality
 Immunosuppression
 Pregnancy
 Elderly Patients – 65 years and over
 Sickle Cell Disease
 Autoimmune Disease
 Vesico ureteral reflux (VUR).
 Intravenous drug abuse (IVDA)
 Chronic debilitating disease
ETIOLOGY
 Staphylococcus aurous :release from distance sources

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  Injury to the kidney
 E.coil (Escherichia coli)
PATHOLOGY OF RENAL ABSCESS
 Glomerular diseases
 Acute pyelonephritis
 Vascular disease
 Acute tubular necrosis
 Kidney stones (Nephrolithiasis)
 End stage renal disease
 Cancer
PATHOPHYSIOLOGY
Infection of renal tissues by pyogenic bacteria

Inflammation of renal tissues

Destruction of tissues, necrosis, pus formation

Capsule developed around pus

CLINICAL MANIFESTATIONS
 Fever, chills, loin pain
 Weight loss
 Excessive Sweating
 Abdominal pain
 Hypotension
 Bloody Urine
 Fatigue
 Costovertebral, flank, lumbar, lower chest, or back pain, Usually unilateral
 Nausea and vomiting
 Dysuria
 Palpable Unilateral Flank Mass

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  Extreme tenderness over the affected kidney

DIAGNOSIS
 Urine Examination :
 Hematuria – Blood in urine
 Proteiuria – Protein in urine
 Blood Examination
 Hemoglobin – Decrease hemoglobin is a sign of anemia
 Increase white blood cell count
 Blood Culture
 X – ray Finding
 Radio opaque shadow observed around if abscess is large.
 Enlarged kidney
 Ultrasound
 Kidney Abscess is observed around kidney – a diagnostic finding of large
perirenal abscess.
 Size of kidney is enlarged suggesting possible renal abscess.
 CT Scan and MRI
 CT scan and MRI differentiate the intra renal (inside kidney tissue ) and extra -
renal ( outside kidney abscess.
 IVU
 Space occupying lesion obliterating or compressing group of Calyces & or a part
of the ureter
MANAGEMENT
 Abscess drainage- Percutaneous, retroperitoneal drainage- Abscess is a drained from
outside and catheter is left for continuous drain and daily injection of antibiotics
 Antibiotic treatment: may be enough in smaller abscesses (< 3 cm) but is usually paired
with abscess drainage to avoid complications
 Broad spectrum if unclear source
If urinary source cover typical urinary pathogens
a) Ceftriaxone 1g IV

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 b) Piperacillin-Tazobactam 4.5 g IV
If hematogenous spread considered, cover for MSSA and MRSA
a) Vancomycin 15-20mg/kg IV
 Treatment of concurrent diseases and/or complications
 Percutaneous nephrostomy may be required in cases of obstructive uropathy.
 Urolithiasis should be treated in patients with renal obstruction due to urinary stones.
NURSING MANAGEMENT
1. Acute pain related to inflammation, secondary to abscess.
2. Excess fluid volume related to sodium and water retention.
3. Impaired urinary elimination related to disease process.
4. Risk for infection related to rupture of abscess.
5. Stress and anxiety related to disease.
NURSING INTERVENTIONS
 Assess vital signs.
 Administer all prescribed medications.
 Give analgesics to relieve pain.
 Give diuretic drugs to increase urination.
 Encourage the patient and provide emotional support to relieve stress and anxiety.
 Monitor lab reports.
 Educate the patient about surgical procedure and check for informed consent.
COMPLICATIONS
 Perinephric abscess.
 Rupture of the abscess.
 Secondary spread of purulent infection into the retroperitoneum.
 Sepsis/ urosepsis.
 Development of a sub-diaphragmatic abscess.
 Fistula formation to the stomach, small bowel, or lung.
 Perforation into the abdominal cavity or the colon.
 Risk for Infection.
 Renal failure.

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  Emphysematous Pyelonephritis (EPN)
 Emphysematous Pyelonephritis (EPN) is a serious complication that result rapid
deterioration of general condition and destruction of kidney tissue.
 Complication is observed in diabetic patients only.
 Kidney Failure
 Kidney infection can cause severe kidney damage that results in kidney failure
CONCLUSION
Renal abscess is a term used to describe a spectrum of diseases that encompass various
intrarenal infectious processes, such as acute focal bacterial nephritis (eg, lobar nephronia, focal
pyelonephritis), acute multifocal bacterial nephritis, emphysematous pyelonephritis,
and xanthogranulomatous pyelonephritis (XGP). Renal corticomedullary abscess is caused by
ascending spread of bacteria; in contrast, renal cortical abscess (ie, renal carbuncle) is caused by
hematogenous spread of bacteria. The most common predisposing risk factors for renal abscesses
in adults are diabetes mellitus, nephrolithiasis, and ureteral obstruction. In the pediatric
population, urological abnormality (vesicoureteral reflux [VUR], ureteropelvic junction
obstruction, and calyceal diverticulum) and urolithiasis are the most important predisposing risk
factors. Although kidney and perirenal space infections are uncommon, they can exact significant
morbidity and carry a risk of mortality, especially if diagnosis is delayed. However, the diagnosis
is not easy to make without imaging studies. The clinical presentation of renal abscess may be
nonspecific, and can include fever, nausea/vomiting, flank pain, and abdominal pain. Laboratory
findings include elevated erythrocyte sedimentation rate, leukocytosis, and positive blood/urine
cultures.
BIBLIOGRAPHY
1. Patterson JE, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin
North Am 2014.
2. Judith A Witworth, J R Lawrence.Textbook of Renal disease. Churchill
Livingstone; Subsequent edition.
3. Richard J. Johnson & John Feehally & Jurgen Floege & Marcello Tonelli.
Comprehensive Clinical Nephrology, .6th Edition
4. https://emedicine.medscape.com/article/440073-overview
5. https://www.researchgate.net/publication/6984892_Renal_Abscess/citation

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 6. https://www.ncbi.nlm.nih.gov/pubmed/16798166
7. https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-5-50

NEPHRO UROLOGICAL NURSING

SUBMITTED TO: SUBMITTED BY:

MRS.REXY.C.D DHANYA K CHANDRAN
ASSOCIATE PROFESSOR II MSc NURSING
WESTFORT COLLEGE OF NURSING WESTFORT COLLEGE OF NURSING

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SUBMITTED ON
27/03/2020

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