Chronic pyelonephritis and Reflux

Nephropathy

Lecturer: PhD. S. Mamatova

Objectives
• Identify and explain etiopathogenesis of
chronic pyelonephritis and reflux
nephropathy .
• Differentiate symptoms and clinical
syndromes.
• Prescribe appropriate treatment.
Lecture plan:
• 1. Definition, epidemiology, etiology (risk
factors), pathogenesis and classification of
chronic pyelonephritis and reflux
nephropathy .
• 2. The clinical picture, the data of laboratory
and instrumental studies.
• 3. Diagnosis, treatment and prevention.
Lecture plan:
• 1. Definition, epidemiology, etiology (risk
factors), pathogenesis and classification of
chronic pyelonephritis and Reflux
Nephropathy .
• 2. The clinical picture, the data of laboratory
and instrumental studies.
• 3. Diagnosis, treatment and prevention.
 Chronic pyelonephritis and Reflux Nephropathy

Pyelonephritis - from the Greek "pyelo"

(pelvis), "nephros" (kidney), and "itis"
(inflammation)
Chronic pyelonephritis (CP) - chronic
nonspecific
infection - inflammation process with a
primary lesion of interstitial tissue, renal
pelvis and renal tubules with subsequent
involvement of the glomeruli and blood
vessels of the kidneys.
Chronic pyelonephritis is usually associated with
• urinary obstruction or reflux;
• results in scarring of the involved kidney, and
• gradual renal insufficiency.
Chronic pyelonephritis
Probably arises from
• UTIs,
• vesico-ureteric reflux and
• consequent renal scarring in childhood

It can be divided into two forms:

• chronic obstructive pyelonephritis and
• chronic reflux-associated pyelonephritis
• Chronic Reflux-Associated Pyelonephritis (Reflux
Nephropathy)

This is the more common form of chronic pyelonephritic scarring and

results from
• superimposition of a UTI (urinary tract infection) on
• congenital vesicoureteral reflux and intrarenal reflux.

Reflux may be
• unilateral or
• bilateral;
• thus, the resultant renal damage either
• may cause scarring and atrophy of one kidney or may involve both
and
• lead to chronic renal insufficiency.
• The incidence of chronic pyelonephritis is
from 1 to 3 - 4 cases per 1 000 population.

• Both acute and chronic pyelonephritis is more

common in women.
Urinary tract infection
• Urinary tract infection (UTI) is one of the most
common conditions seen in general practice,
accounting for up to 6% of consultations .
• 20% of women at any time have asymptomatic
bacteriuria and
• 20–40% of women will have a UTI in their lifetime.
Factors predisposing to the development of chronic
pyelonephritis:
• acute pyelonephritis;
• urological manipulation; retrograde pyelography;
сatheterization
• hypothermia;
• urodynamics disorders (stones, urinary tract tumor,
prostatic adenoma);
• pregnancy;
• diabetes;
• chronic infections in the upper respiratory tract, oral
cavity;
• Genetic predisposition to chronic pyelonephritis,
L. Gender
• 1. Females
a. Increased sexual activity
b. Pregnancy
c. Atrophic vaginal mucosa predisposes to the colonization of
pathogens and UTIs.
• 2. Males
a. Homosexuality
b. Uncircumcised penis
c. Sexual partner with colonization
d. Obstruction: Prostatic hypertrophy
e. Age 50 years or older
f. Acute or chronic bacterial prostatitis
 Etiology and pathogenesis
• The main etiological factor - the penetration of the
infection into the urinary tract, pyelocaliceal system,
interstitial kidneys tissue.
A. Pyelonephritis is due to ascending infection from
the bladder usually caused by E. coli (Escherichia
coli), (>70%), of patients).
• Proteus mirabilis, Proteus species, Proteus vulgaris,
Pseudomonas aeruginosain
• Enterococcus
• streptococci,
• staphylococci
 Pathogenesis
• B. Bacteria can also reach the kidneys through
the bloodstream .
• C. In women, the short urethra in close proximity
to the perirectal area makes colonization
possible.
• E. In men, BPH causing bladder obstruction is a
common pathology.
• F. Indwelling catheters increase ascending
infections and pyelonephritis.
Classification of chronic pyelonephritis
(Lopatkin NA, et al., 1992).
I. Pyelonephritis
• primary (not associated to the previous
urological disease);
• secondary pyelonephritis (on the basis of
lesions of the urinary tract of the urological
nature).
Localization of the inflammatory process:
• unilateral pyelonephritis (right, left);
• bilateral pyelonephritis;
• total pyelonephritis (affecting the entire
kidney);
• segmental pyelonephritis (affecting a
segment or portion kidney).
Morphology :
• One or both kidneys may be involved, either
diffusely or in patches.

• The hallmark of chronic pyelonephritis is

scarring involving the pelvis or calyces, or
both, leading to papillary blunting and marked
calyceal deformities
Clinical picture
Complaints of patients can be divided into two groups:
common and specific.

Common complaints include:

• fatigue,
• decrease in working capacity,
• poor sleep,
• decreased appetite,
• headache,
• fever,
• malaise,
• vomiting
Specific complaints of chronic pyelonephritis:

• • Pain in the lumbar region (often unilateral)

aching nature, sometimes quite intense
(painful form), may radiate to the lower
abdomen, genitals, hip;
• dysuria and urinary frequency

• dysuria (painful frequent urination that due to

concomitant cystitis);
 Specific complaints of chronic
pyelonephritis(cont.):
• the allocation of turbid urine, sometimes with
an unpleasant odor, giving the muddy
sediment upon standing (sometimes
purulent);
• chilling in severe exacerbation, sometimes
transitory body temperature rises up to 38.5-
39 °
Mild pyelonephritis can present as
• low-grade fever
• with or without lower-back or costovertebral-
angle pain, whereas
Severe pyelonephritis can manifest as
• high fever,
• rigors,
• nausea,
• vomiting, and
• flank and/or loin pain.
• Symptoms are generally acute in onset, and
• symptoms of cystitis may not be present.
• Fever is the main feature distinguishing cystitis
from pyelonephritis.
• The fever of pyelonephritis typically exhibits a
high spiking “picket-fence” pattern and resolves
over 72 h of therapy.
• Bacteremia develops in 20– 30% of cases of
pyelonephritis.
Inspection:
• pale skin and visible mucous membranes;
pastosity face;
• for chronic pyelonephritis are not typical
pronounced swelling;
• pain on palpation of the lumbar area (often
unilateral);
• hypertension (it is less stable than in chronic
glomerulonephritis).
• With the progression of chronic pyelonephritis
gradually developed chronic renal failure
The examination program
• 1. CBC, blood culture
• 2 urine analysis, urine culture
• 3. Determination of bacteriuria
• 4. Examination of urine for antibiotic
sensitivity testing .
 Laboratory data
1. Blood analysis:
• signs of anemia,
• leukocytosis,
• increased erythrocyte sedimentation rate.
 Urine analysis: :
• urine muddy, alkaline reaction,
• moderate proteinuria,
• microscopic hematuria,
• Urine microscopy reveals expressed
leukocyturia, pyuria (leukocytes in the urine).
• possible cylindruria, bacteriuria
• The detection of bacteria in a urine culture is
the diagnostic gold standard for UTI;
• Renal ultrasonography
• Еxcretory pyelography

• A. Urine culture and sensitivity should always

be performed before initial empiric treatment
with antibiotics.
• B. Urinalysis for evaluation of pyuria.
Pyuria is present in almost all women with
acute cystitis and pyelonephritis; its absence
• strongly suggests an alternative diagnosis.
Diagnostic criteria.
• 1. Pathognomonic clinical signs: dysuria,
polyuria, Therefore
• elevated body temperature, chills, pain in the
lumbar region.
• 2. Bacteriuria (more than 100 000 microbial
bodies in 1 ml of urine)
• 3. Changes in urine sediment (leukocyturia,
microhematuria
Pathognomonic radiographic signs (excretory
pyelography):
• deformation pyelocaliceal system
• pyeloectasia
• increase renal cortical-index,
• a decrease in the thickness of the
parenchyma at the poles.
5. Ultrasound signs:
• asymmetry kidneys size, expansion
• and deformation of the pyelocaliceal system,
• acoustic heterogeneity of renal parenchyma,
• kidneys contour irregularity.
Differential diagnosis:
• differentiated from asymptomatic bacteriuria
• kidneys tuberculosis,
• glomerulonephritis
 Dietary management
• 1. Increase fluids; have the patient drink at
least one large glass of water every hour while
awake.
• Fluid intake (>3L/24h)

• Monitor urinary output.

Pharmaceutical therapy
• 1. Acetaminophen (Tylenol) for fever
• 2. Urinary analgesic as needed to relieve
dysuria. Dysuria is usually diminished fairly
quickly after the start of antibiotics.
• 3. Antiemetics as needed; however, if the patient is
not able to tolerate oral fluids, he or she should be
hospitalized.
• 4. Antibiotics: Empiric antibiotic selection should
be guided by local antibiotics resistance patterns,
allergies, and culture results. Patients with delayed
response to therapy should also receive a longer
course of antibiotics of 14 to 21 days.
• Antibiotic therapy.
• The choice of antibiotic depends on the species and
antibiotic sensitivity profile of the infecting
organism, and may include 

• Fluoroquinolones : ciprofloxacin
• Trimethoprim TMP-SMX
(trimethoprim/sulfamethoxazole)
• Semi-synthetic penicillins: ampicillin ; Amoxicillin ;
• Cephalosporins : cefriaxone
• 1. First-line therapy: Ciprofloxacin (Cipro) 500 mg
twice daily for 7 days. A 7-day course of therapy
with oral ciprofloxacin (500 mg twice daily,
• with or without an initial IV 400-mg dose) was highly
effective for the initial management of
pyelonephritis in the outpatient setting.
3. Second-line therapy: Trimethoprim and sulfamethoxazole
(TMP-SMX) (Septra DS, Bactrim DS) 160 mg and 800 mg,
respectively, one tablet twice daily for 7 to 10 days.
Because of the high rate of resistance of E. coli, the
empirical use of TMP-SMX should be avoided in patients
who require hospitalization.
4. Alternative therapy: Amoxicillin-clavulanate (Augmentin)
500 mg/125 mg orally twice a day for 14 days OR
• Augmentin 250 mg/125 mg orally three times a day for 3
to 7 days.
• Oral TMP-SMX
(trimethoprim/sulfamethoxazole)
• (one double-strength tablet twice daily for 14 days)
also is effective for treatment of acute
uncomplicated pyelonephritis if the uropathogen is
known to be susceptible.
• If the pathogen’s susceptibility is not known and
TMP-SMX is used, an initial
• IV 1-g dose of cefriaxone is recommended.

Oral β-lactam agents are less efective than the

fluoroquinolones and
• should be used with caution and
• close follow-up.
Options for parenteral therapy for
uncomplicated pyelonephritis include
• fluoroquinolones, an
• extended-spectrum cephalosporin
• with or without an aminoglycoside, or a
carbapenem.
Combinations of
• a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-
sulbactam, ticarcillinclavulanate, piperacillin-tazobactam) or
• a carbapenem (imipenem-cilastatin, ertapenem,
meropenem) can be used in patients with
• more complicated histories,
• previous episodes of pyelonephritis,
• anticipated antimicrobial resistance, or
• recent urinary tract manipulations;
• in general, the treatment of such patients should be
guided by urine culture results.
• Once the patient has responded clinically, oral therapy
should be substituted for parenteral therapy.
Antibiotics that should not be utilized for pyelonephritis
1. Nitrofurantoin (Macrodantin) and Fosfomycin (Monurol) should not
be used to treat pyelonephritis in adults or children; it is excreted in
the urine but does not achieve therapeutic serum levels.
2. Ampicillin or amoxicillin should not be used for enterococcal
infections in hospitalized and other institutionalized patients.
3. Fluoroquinolones are not used in children because of potential
concerns about sustained injury to developing joints.
4. Tetracyclines should not be used in children because of tooth staining.
5. Fluoroquinolones are not used in pregnancy due to the risk of auditory
and vestibular toxicity in the fetus.
6. Aminoglycosides are contraindicated in pregnancy due to the risk of
permanent ototoxicity to the fetus.
 Prophylactic measures to be adopted by
women with recurrent urinary infections
• Fluid intake of at least 2 L/day
• Regular complete emptying of bladder
• Good personal hygiene
• Emptying of bladder before and after sexual
intercourse
• Cranberry juice/tablets may be effective
 Main literature:
 
1. Davidson’s Principles and Practice of Medicine 23rd Edition
2018 P. 426-431

2. Kaplan USMLE Step 2 CK Internal Medicine 2014 Lecture

Notes 2
3. Harrison's principles of internal medicine, 20th Edition /
Edited by Dan Longo, Anthony S. Fauci etc. - The McGraw-
Hill Professional. 2018 (Chapter 130: Urinary Tract Infections,
Pyelonephr and Prostatitis p.1/15 )
Thank you
for
attention!